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I WELUPUMP PERMIT <br /> SAH.IOAotAM COMM ENvtROMM WAW HEALTH NPmnmwr 1868 EAST HAMTON AVENUE-STOcXnN CA 95245 -(209)468-3429 <br /> NON-REFUNo PERMrT CAL/L X209 53-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE lssuED <br /> JOB AoDfa ss U Crrr/Ztr <br /> CROSS STREET' D <br /> APN PARCEL Sim LAND USE APPLICATION# <br /> OwMEt NAYF <br /> C1 } PHONE ALV m <br /> OwMER ADDRESS 1 l P CFTYISTATEMP <br /> CONTRACTOR <br /> CONTRACTOR ADDRESS CITY/SrwTElZrPU&10 9f2x <br /> �� <br /> SUBCONTRACTOR <br /> PHONE <br /> SUBCADDRESS CTTYISTATEaP <br /> Licosa 0 ❑C$t a D 09 ❑ Other NtUBER ZZ EXPIRATION DATE Z <br /> DOMESTIC WELL SAMPLIMG:d General UrteraliColiform Bacteria(4391)❑Dibromochloropmpane(4392)D Arsenic(4393) <br /> INTENDER USE riv e ❑ Irrigatbn/Agrirx�itral ❑ industrial a Water Quality MoNkning 0 SOO Sampli g Characterization <br /> ❑ ut> Water System <br /> if dHfarerd from Owner Water Sysfern tlFartre Gardact Name or Phone Number A <br /> TYPs OF WORK�Idew WeII Well ❑Well Att»rataoNModification 0 Other /�/ r Y <br /> ❑ Monitoring Wel(s)_ _#of wefts 0 Soil Bwng(s) a or b_#x;6 ❑Geotechnical ° �O <br /> ❑Out-Of-Service Well ❑ Out-Of-Service Lyell Renewal ❑ Cross-Correction Repair p <br /> ,98 <br /> ❑ New Pum ❑ Pump Replaicerpent ❑ Pump Repair ❑ Raise We!CasingSq N Z <br /> Wed.CONSTRUCTION NE Nil QUIN <br /> Drltitrhg Method tud_Ftciarx Alf Rotary o Auger ❑ gable Tool 0 Push Point D Other (�TNn- F'A N <br /> Proposed Well l ft Excavation la in diameter 0 Open Bottom Gravel PacWGrawl Size in d T <br /> 0 Cond Casing in diameter / Conductor Casing Depth R NT <br /> Welf Casing Diameter ThicknesslGaugefASTM Std 0 Steel Plastic D Stainless Steel 0 other <br /> C�rotrt Seal ft 0 Pleat Cement(94 ib bag^5-1D gat waW D Cement sack mbd 7 gal water <br /> colds) ❑Other <br /> Grotri �M lliumped 0 Free Fall D Other 0 Retardant f Acwk ator(name) <br /> taatalW By D Driller D Ptanp Contractor D Other <br /> ❑ConCmte Pedestal❑DHnensiasns:Widthft LengttT ft Thick <br /> in 0 Christy Box ❑ Shove Pipe <br /> Pump ❑Submersible❑Turbine 0 Other HP Purnp Set ft Standmo Water L.L-M ft <br /> Plot Plan Requireme!03: Attach a plot plan with the enact location of water well with respect to the fonowing items: GPS <br /> Coordinatt's, property lines, adjoining properties, water bodies or coarses, drainage pattern, Toads, e>6sting wells, structures, <br /> potential sources;of contamination,sewers or private disposal systems.Include distance from two property Hines.Icor Domestic, <br /> Agriculture,Industrial well,provide]location of any water wells or surface water within 200'radius of proposed we1L <br /> MDWI WM 2l HOUR ADVANCE NOTICE REQuutED FOR INSPECTIONS-MEASE CALL(299)953-7697 <br /> EPARTMENT USE NLY (� Q- <br /> APP B]r Date 2d ZZ Arita I g Empllcyyee!t1# <br /> c"xA BY Date ❑ SPECIAL.well Permit <br /> P—P hapection By Date ❑ WAivER Received <br /> Soa Barkv inspeatior►BY Date Constructed Well D"M ft <br /> COMMENTS <br /> PE SC Recelvad Check& Re d slate �w # evoke# WeH tD# <br /> cotes Info BY, Cash se� <br /> o d z- <br /> 91 <br /> 5l•oo <br /> F]ID043-%GWr1tr7.2 Pag I On Wa/Pump Parvo[ <br /> l iossgzS7 <br />