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i WELL/PUMP PERMIT <br /> SAN JOA04M COUNTY EWMONNENTAL HEALTH DEPART1i mT 1868 EAST HAmToN AvENUE-SToCKToN CA 85205 -(209)4683420 <br /> NON-REFuNoAAPERmrr CALL 209 53-7697 FOR INSPECTIONS EXPIRES 1 YEAR FRoM DATE ISSN <br /> m <br /> JoeADDREss U��}''� �•(h CnYf� <br /> CROSS STREET APN PARCEL SIZE LAND USE APPLICaTTor1# <br /> OWNER NAuE � !—J7J PHONE r m <br /> OWNER ADDRESS 1 t T C1TY.ATE.P 0 j <br /> COMiRACTOR <br /> CowTRAcToR ADDREss CIT7/STATEMP <br /> SUBCONTRACTOR PHONE <br /> SU ADDRESS CFY1STATEIZB <br /> ;TC-57 ❑ "1 ❑ D-09 ❑ Other NurreER ZZ EXPIRATION DATEII�l 2 7-7 <br /> DOuEsTIc WELL SAupuuG:a General NneraUColiform Bacteria(4391)C Dibromochlornpropane(4392)L Arsenic(4393) <br /> INTENDED USE rNate ❑ InlgatkxVAgricktabral ❑ Industrial ❑Water Quality Monitoring ❑ SON SamplinglCharacterization <br /> ❑ ut*c Water System <br /> h dtf&wt km Owner. Water 9yMem Name Contact Nam or Phone Number <br /> TYPE OF WORK PNew Well Well 11Well AtteratioNMoci fication L1Other /:� ccJ T <br /> D Monitoring Wel(s) #of wells 11Soil Boring(s) 901i>0nng% te❑ Geotechnical *°r °n `O <br /> ❑Out-UService well D out-Of Service well Renewal L1 Gross-Connection Gross-Connection Repair JD <br /> ❑ New Pum 0 Pum t ❑ Pum Repair ❑ Raise Wel Casing `Sq.l� 0 2 <br /> WELL COMMUCTION <br /> NV QUl <br /> Drilgng Method*ud- Air Rotary ❑ Auger ❑ cable Tool ❑ Push Point a Other NL1 THRONMN C N <br /> Proposed Weil Depth ft Excavation I` in diameter ❑ Open Bottom �t Gravel Pack/Grael Size in <br /> ❑Cond Casing in diameter / Conductor Casing Depth '` ft <br /> Wal Casing Diameter Thidkness/&vWASTM Sched ❑ Steel XPiastic ❑ Stainless Steel D Other <br /> Grout Seal Depth ft O Neat Cement(94 1b bag5-10 gal water j [],Sand Cement sack mhd7 gal water <br /> colds) o Other <br /> Graut Plaoemarrt M umped D Free Fall ❑ Other ❑ Retardant/Acce+erator(name) <br /> PEDWAIL Installed By ❑Dr17Jer D Pump Contractor D Other <br /> D Contrets Pedestal❑Dimensions:Width ft Length ft Thick <br /> lin ❑Christy Box ❑ Stove Pipe <br /> PUMP L1 Submersitie❑ Turbine ❑ Other HP Pump Set ft Standing Water Level ft <br /> Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the following items: GPS <br /> Coordinates, property tines, 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,provide location of any water wells or surface water within 200'radius of proposed well <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> EPARTIIENT USENLY �] <br /> Application Accepted Date LO ZZ Area d ` 1 Employee ID# _ <br /> Grout Inspection Date ❑ SPECIAL Well Permit <br /> Pump inspection By Date D WmvER Received <br /> Sof Inspection By Date Constructed Well Depth ft <br /> v <br /> PE SC Recelnred MrarJl V Amount Dale Permit/ ktvoice# wet IDE <br /> Codes Info Sema # <br /> 0 0 Zo Z� z <br /> 91 1ss <br /> 2 (o <br /> 5t•oo <br /> F7m0/1-9601A77r2022 PW 1 d2 V&H Pwy Paw <br /> 1,50S. 9728-7 <br />