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�2zSoS� <br />WELUPUM PERMIT <br />Sm JoAauii i Goupdw EKMROMMENTAL. HEALTH DEYARTSIMMT 15 FAST HAZELTON AVENUE = STOCK OR C, 95205 • (209) 468-3420 <br />t+evrrr-ester-t,dNDABLE PERMIT GALS 953-7557 FOR INSPECTIONS y ,EXP'IRES I YEAR FROM DATE ISSUER <br />JOE,C Cas i _ _ _ C"/Zip _'—fel q5 2 1jo <br />,may, <br />CROSS STr EEI'6 _ d� APN _ � Q --Y PARCEL SEE _19ANo USE A <br />P <br />P <br />LI <br />CATION # <br />OWNER hEf.mr.-3zdie.bahi/'--- --- PHONE <br />OWNER IDiEr 1 i®5 E. <br />COKMACTOR Me -*,1 O.. A!'ndL��tArt� A 9f ffQ_L. L��if�► Fp PHONE X_ � 36-4— 22, <br />CONTRACTDR AaurtEss _- CMISTATEMP <br />SUBCO TOR __ 156'`rnQ� oci U%LQ PHONE �lfLyY�t� Ctb `it.OJ\/� <br />Cif •Vr SOP) ADDRESS <br />0TYISTATE/zIP -- <br />9 C-57 ❑ C-01 0 D-09 ❑ Other Puu6m ExwiRATiow <br />DOMESTIC WELL SMPLIWG: C General Mineral/Coliform Bacteria (4391) Dibrornochloropropane (4392) C, Arsenic (4393) <br />krEMM UM ❑ Domestic/Private D Irrigation/Agricultural 0 Industrial ❑ Water Quality Monitoring JI Soil Sampling/CharacteftMion <br />0 Public Water System <br />e different from Owner. Water System Name Contac) Name w None Number <br />rvi' yr b'VlBR61i u rvesW nM 671 u neplacemem weii U Well AperationfMOdification 0 Other <br />❑ Monitoring Walls) # of wells O Soil Borings) got bmlrr s 19 Geotechnical _ 2- <br />0 Out -Of -Service Well 0 Out -Of -Service We0 Renewal 0 Cross-Conneclion Repair T <br />0 New Pump 0 Pump Replacement D Pump Repair 0 Raise Well Casino <br />N of borings <br />PA <br />OfIlitng Method 0 Mud Rotary 0 Air Rotary 0 Auger El Cable Tool 0 Push Point 0 Other__ _ <br />Proposed Well Depth_ tt Excavation In diameter 0 Open Bottom 0 Gravel Pack/Gravel Size In etf <br />0 Conductor Casing in diameter / Conductor Casing depth fl <br />Well Caaing Diameter in Thickness/Gauge]ASTM Sched 0 Steel Cl Plastic 0 Stainless Steel 0 Ottler SAN �CAQ <br />Grout Seal Depth_- . __ f1 0 Neat Cement (941b ba95-10 gal water) 0 Sand Cement sec1 <br />0 Bentonite (20% solids) 0 Other P <br />Grout Placement Method 0 Pumped VfFree Fall 0 Other 0 Retardant / Accelerator (name) <br />PEDESTAL fnstalled By 0 Driller 0 Pump Contractor ❑ Other _ <br />0 Concrete Pedestal ❑Dimensions: Width R Length ft Thick <br />in 0 Christy Box 0 Stove Pipe <br />1EM D Submersible❑ Turbine o Other _ HP Pump Set_ R Standing Water Levet ft <br />Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the following items: CP'S <br />Coordinates, property lines, adjoining properties, water bodies or courses, drainage pattern, roads, existing wells, structures, <br />potential sources of contamination, sewers or private disposal systems. Include distance from two property lines. For Domestic, <br />Agriculture, Industrial well, pravide location of any water wells or surface water within 200' radius of proposed well. <br />MiN1;NUAt La IiUUk U)U ,INCL NO] ICE REQUIRED POR LNISPECT70NS - PLEASt ALL(209)953-7697 <br />DEPARTMENT U91E PNLY <br />Application Accepted By Dale <br />Grout Inspection By Date <br />Pump Inspection By _- Date <br />Soil Boring Inspection By <br />COMMENTS <br />PE. . <br />Codes <br />WJ 72 <br />Date <br />0 <br />Area Employee ID# <br />W�ii Permit <br />0 WAIVEn R Cawed <br />Well D6^,' .__ _ .. <br />ft <br />I� <br />m <br />•�VNT <br />D <br />� 2027 <br />NT,�L <br />2T /4'ENT <br />SC R'eesived <br />Into _ <br />C Amount <br />Remitted <br />Date Permit/ <br />a Re uest # <br />Mvoic # <br />Well iD# <br />l <br />FS <br />� <br />rt+DO43.06 WA717022 <br />I TU <br />Pate I of Z <br />W.11 I Rrrr Permit <br />