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"Vee L ILL#?U M P Fir. I T <br /> 'A(YAN COUNTY ENVIRONMENTAL HEALTH DEPARTMKFN V^Mi3 k_.,'.\.'!THAZELTON AVENUE-STOCKTON CA 95205-6232 (209)468.3420 <br /> REFuNDABLE PERMIT 101MIPIRES I YEAR FROM DATE ISSUED <br /> LA <br /> Z­')RES� lag6g 6, nk 6A I CITY/ZIP 411 M <br /> V_ - -11 > <br /> % a <br /> _1 LAND USE APPLICATION# <br /> STRE� VZ1 PARCEL SIZE'70,� <br /> 19Ljoil <br /> M <br /> Irv;NAPAF PHONE <br /> JcR ':2 '�ITYGTATEMIP <br /> ADOR6. 27%,,!'] 15. Wl <br /> PHONE <br /> 1)w V<6n lzl!�e <br /> ";A31 ADDRESS elr' ni(? <br /> i ORICO)NSULTANT <br /> .:.%N-,RAC70RIQONSULTANT ADDRESS <br /> V457 C-61 D-09 Other NUMBER EXPIRATION DATE <br /> D OWNER *eONTRACT01.1 SUf3CoN-E'RPC.TL1;?ICONS(ILTAt4l' <br /> General Mineral/Colifo IT- <br /> n Bacteria(439,1)'-" Dibromochloropropane(4392)'-*Arsenic(4393) <br /> vf)omestic/Private i; Irrigation/Agricultural Industria! Water QL!al!tV Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If different from owner Water System Name Contact Name or Phone Number <br /> /tic Well Replacement Welf Well Alteration/Modification Other :4 ► <br /> Monitoring e (s) #of wells Soil Boring(s) of borIngs Geotechnical #of borings V <br /> � <br /> Out-Of-Service W Out-Of-Service Well Renewal Cross-Connection Repair 11I <br /> 64 <br /> I <br /> New Pump ./Pump Replacement Pump Repair Raise Well Casing A <br /> qSTRUCTION6428 <br /> 1V i <br /> M,_thod :: Mud Rotary i 1 Air Rotary 1 Auger Cable Tool Push Point Other j L-I.VV (i/tv <br /> Af-If Depth ft Excavation in diameter Oven Bottom -.*. Gravel PaclVGrival Size OU/Vl. <br /> 4� Js�jv <br /> C <br /> Conductor Casing_in diameter / Conductor Casing Depth ft7,4L V <br /> :,Ing Diameter in Thickness/Gauge/ASTMness/Gauge/ASThickness/Gauge/ASTMSched Steel '7 Plastic :: Stainless Steel Other ENT <br /> Depth_ft Neat Cement(94 lb bagl5-1 0 gal water) Sand Cement sack mix17 gal water <br /> Bentonite(20%solids) 7 Other <br /> illttcement Method 1, Pumped Free Fall Other Retardant/Accelerator(name) <br /> 'L Installed By G Driller Purno Contractor Other <br /> Concrete Pedestal_Dilmenslons:Width__ft Length__ft Thick in .. Christy Box Stove Pipe <br /> lz-!.. bmersible;_; Turbine :. Other- Standing Water Level ft <br /> THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCOPDA"'ICE WiITH SAN <br /> 'D L11C!_'-'VSE IS <br /> WFA.' ORDINANCES, S 5�TE LAWAND RULE-3 AND REGULATIONS. I ALSO CERTIFY THAT MY RE RL <br /> 7F I *NSr -,, 11 - <br /> TIVE WITH THE AL" ORNIA STA Xri K Z.DA.'0 AND THAT I AM IN CONWIJAMOF wrm ALL <br /> in <br /> E NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> n� DATE <br /> _T <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date_V2-y? z0710 Area Employee ID#_ <br /> Grout Inspection By !! Date 0 SPECIAL Well Permit <br /> Pump Inspection By 'ff kAg;5"Q Date El WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received (�k#/ Amount Date Permit/ <br /> Codes Info Bv Uash Remitted Service Request# Invoice# Well ID# <br /> 9391 DS-0 T7 �77 <br /> 't Q 70(0 <br /> I <br /> EHD 4306 6/1112019 WELL/PUMP PERMIT <br />