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of � f <br /> 1 WELUPUMP PERMIT <br /> SAN JoAQtm Cotlrirr EmvwowrewTAL HEALTH DEPARTUENT I en EAST HA2ELTON AvEm)E-STOCKTON CA 95205 -(209)468-3420 <br /> NON•REFtMOAKE PERMIT CALL 209 953-76 7 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS enc C.IZl <br /> CRM ST EET APN 203-O N- a 16 PARCEL SIB�LLa o USE AMLICATtOw� q <br /> ONO3R NAMnYf) PHONE 2 <br /> OW,WI ADOwEasLljj� U arY/sTATElLP 9 53 CO <br /> CON►RA.Tm HayJlb PY11100PHONE ?��52�Z-- II g21A <br /> CONTRACTOR ADDREss AibeCrrfWAWfZIPE t <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR Aooms9 CrTYMTATE P <br /> LICENSE C-57 0 CS1 O D-W ❑DOW NtmeER lfl — EvveATION DATE D Z <br /> DowEamc WELL SAMPLnG:(If General Mineral/ColHarrn Bacteria(4391)❑Dlbromvchloropropane(4392)11 Arsenic(4393) <br /> INTENDED last1KDorrwstkJPrtvate ❑ rrigadonlAgricd Mal ❑ kAnhial 0 Water Quality Mortoling 0 Sod Sarnplingtfharactertzatlon <br /> 0 Pubic water System <br /> It Mment tom Omer WNW%taem Nana Ca ad Naarie or Ru"Nu Ow <br /> jYK OF WOMK vNew Weil ❑ Replacement well ❑Well AllierationlModification ❑ Other <br /> ❑ Monkoring Well(s) #of weft ❑ Sol Bod g(s) w or mrw9s ❑ GeOkK tviical 9or Wrgs <br /> 0 O t-01Service Well ❑ Out-OR-Service Well Renewal 0 Cross-Co necion Repair <br /> ❑New Pump ❑Pump ❑ Repair 0 Raise Well Casing <br /> Wym COwiTftxT M <br /> Drilling Mettwd 0 Mud Rotary n Air Rotary 0 Auger 0 Cable Tod ❑ Push Point ❑ Other <br /> Proposed Well Depftt -(On ft Excavation_ l2 in diameter ❑Open Bottom Gravel Pwk ,ravel Sae in diameter <br /> ❑Cor>du Ca4kig in dfarrie/ar ! Conductor Casing Depth R <br /> Wadi Casino Diameter ,u in Th{dviessraugWASTM Schad 2-QQ - ❑ Steel KPiestic 0 Stainless steel ❑OCrer <br /> Grout SaW Depth ZO O ft ❑Next Cement(84 b nag(5-10 gat water) ❑Sand Cerner t sack morn gal water <br /> lite(20%solids) ❑t3ltter <br /> (;rout YxlFwd Purnped ❑ Free Fall 0 Other O Retardant I Accelerator(name) RAYAdrzhur <br /> IrmiNed By ❑Driller 0 Pump Contractor ❑ Other <br /> ❑Conc nets Pedestal❑Dbaern ions:Widlh It Length It Thick <br /> lin ❑Chrlegr Box ❑ stows Pipe <br /> "ZL7z-- <br /> 1ILLM ❑Subnwwsbe0 Turbine ❑Other HP Pump Sot ft Stalldlrg that rl ou1y rou iv ft <br /> PW Plan Regdre®ab: Attach a plot plan with the exact location of water well with respect to the f0U*MMg'4tNftr. GPS <br /> Coordinates,property does, adjoining properties,water bodies or courses, drsiaaSe pattern, roads, ezistiaB welt, structures, <br /> potential sources of contamination,sewers or private disposal systems. Include distance from two property Hues.For Domestic, <br /> Akgricakare,Industrial well,provide location of any water wells or surface water within 200'radios of proposed well- <br /> M MMUM Z4 HOUR ADVANCE NOTICE REQUIRED FOR INSPEC ]IONS-PLEASE CALL(209)953-7697 <br /> DEPARTMENT US ONLY L/ p <br /> Application Accepted By Date o 22 Area / / Employee IDMr <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAim Received <br /> Sot Bari„ Inspection By Date- Construclsd Wea Depth R <br /> COMMENTS <br /> PE SC Rscslvsd Check& Amount Dad Iwvoics/ WOR wo <br /> Codas Into ev Cash Sarvloe RequNd 0 <br /> 70 0 0 Z <br /> `/ S (iewli <br /> 4 <br /> \/ CD I{ 8 <br /> EAo.ws owrrmn Z Z ( 2 Weil rasa rani <br />