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11 1 ' WELUPUMP PERMIT <br />SAN, oAakum Coumy EslviRoha►Err-AL HEAL -n, DEPARTMENT 1866 ZA HAZELToN AvEwjF • STOCKTON CA 96245 - (US) 486-342 <br />ION-REFUNDADLE ftRmiT CALL (209) 953-7697 FOR INSPECTIONS EX ice:; -;=S 1 YEAR FROfd DAT'_ lssu= <br />Joe AaEss ,rtVr�C�,-�(�:._�2�Sd2 cr Y2is ���C-S�iot1 a 5 2.1 rj <br />i:ROSS 3rrteE l'! O� �� - )LL 6� _Ai'N-� _lceRC4-1 Sda �443E/MMr-ArKmt_ <br />OvVN' NAVE � Th — dt t e�. <br />O•tNER Aana,ESS �a< CITY%STATErZIP_ caI W } ` <br />coNis,.:c oR C&k ujA.i+e t( oC-ICA <br />�/ PHON _ 3 <br />CONTRACTOR Aa ss . 5__ f��'f O _ _ _ CITY/STATEMP . p <br />- <br />3uaconTTtAr, Qv ron _ -- -- _ -_ - - - --_— - -- - _ P�tE <br />SLA=NTRACTOR ADOREss - CITY/STATE(ZIP <br />Ltd j r,.st _ I Jttter 43y �� Se P,q_3y��i� <br />_. _--- E�tstATTON Da <br />i}r?r�£STtC WE;t SAsaPtaaB: General eral;Coliforrn Bacteria 44391) Dibramochlorapiroparte ( +t�/V T <br />-- _ 4392) Ar9enic <br />iNTENZc ED Us DonesbuPrivft lrrpfi0,VA9riW%yn1 ' tnd"biai- - ylta�r a ty iy t Sou Sa A UG r <br />- �ei., <br />t1MM0WW WKIr sem,�3TYGS 2E 1 Q.St Repbwrnertt Wait Well APdvzt.ot0&o--&ca9::,.^ A <br />- r�IiYr - f IE <br />Monitowed(s) >: of ,malts coil Bonn;(s) -- = •x Ccxu s veote Ta <br />m-ri <br />G<s! O�Serrce "Neilc`hii-Ot ^ YtGe WedRe^w i.�! : r� Reaalr r <br />_ New PuraD punto PAO&ernent Pump fir Raise Wel; casino <br />-- <br />Dri:fing Method A#ud R&t)r; Ar Rotary Auger Caoie ToPush Pc%rr, 0 lar'►�i <br />Proposed Weil DQPttt b 50 $ ExcavaCoin - c�� :n e:arnete, GPea 3ottom itavnJ P3Ck G—Zl eI Ze _�_ in 4:arric!f: <br />oruiur,-or st dta'tteter ; conduc or Ga6.n9 Devil tt <br />'NOM Cas: ng Diameter 1(ie tr` Thickaess/CaugaiASTRf Sated • 31 a 5trei Plastic Stainless Sae, Other__ _ <br />Grout Seal Ce?,h SO ti NMI Cement (S4 th NDW5540 gel oaten and Cemant___ 0 -- old` ntnd7 Bay yt _ <br />Bentonite (2055 sokdsi Otrta <br />Grout Piarent,)rt(dethad ✓?um Free Fadi Gtner Rebwdft/AcnMaaloriMrte) -- --- <br />10"-wfed Sy E -Wer FJKI^ Contractor -- Otl:er-- <br />i r7 Concrete "tedesta! _ Z)imens!ars- Wictn- ft Length ft Thk* -- -- <br />'!n U Christy Sox stone Pigg -- <br />Pu�P 4 <br />•, ther Sucmersible T -i bine . O -- - HP _ - -- '— ft SWidirg Aaw t_2:Ri <br />UrnP Suetft <br />Plot Pian Regsiremenn: Attach a plot pian with the exact location Of nater well With respect to the foijewing items: CPS <br />Coordinates, property limes, sclioining properties, water bodies or courses, drainx;e pattern, roads, existing wells. structnrm <br />potential sources of contamination, stovers or private disposal lystems. include r±is:auce from two propert-, lines. For Doru-,,,tic, <br />Agriculture, Industrial well, provide lecstioit of an} water wells or surface hrater ovirhin 200' radius of prripa-s ed a% ell. <br />--ki 24 H(.4 kt W: VV is OR J. <br />DEPARTMENT USE ONLY <br />Ap#fcatcr Accepted By _ Z— L, Oaw 6 as <br />---- <br />3rout hcrioa 9y NA5 eW" tete �'?.L <br />Pump Ir specticin By <br />Date <br />SPECIAL Well Permit, <br />WAfVEP Received <br />SW Baring lnspecfson By Gate ConstructedW*N Depth °C <br />c0MUME-as E x e't o by a ofder P-7-22 h e_ N 1b be- 50 EeP 4. f ro <br />ins# <br />11ID0:34b f67! -2F j;14 - ! �/ �� / Prue i R: <br />