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� � 1 1 WELUPUMP PERMIT SAN JoAom COUNTY ENvwmmENTAL HEALTH DEPART ENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-M20 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED 1814q q 6 11a y� � JOB ADDRESS i�y�1� '/1��yn, J/� CrrY/Z/I�PNdhAfW {mbb� CROSS STREET APN 2Z8_ V_6(0Q PARCEL Sa29'5 LAND USE APPLIcATIm# A OWNER NAME PHONE / �Y5-2 a 67 OWNER ADDRESS 1,Aaq ho o CITYISTATEMP OMT '( J 1 CONTRACTOR � � PHONE — f I CONTRACTOR ADDRESS CRY/STATEIZIP SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CrrY/STATE/ZIP LICENSE ❑ "1 0 D*9 ❑ Other NUMBER EXPIRATION DATE 0 l DOMESTIC WELL SAMPLING:U General Mineral/Colifomn Bacteria(4391)D Dibromochloropropane(4392)❑Arsenic(4393) INTENDED USE ❑ DomesUGPrivate hrigaODNAgriculturat ❑ Industrial ❑Water Quality Monitoring ❑ Soil Samphngl T 0 Public Water Syst SCF/l i H afferent firm Owner. Water System Name Contact Name or Phone Ntmber O TYPE OF WOW T*Wen Replacement Well ❑well AMeretionllModification 0 Other /74 Ly +Monitoring W s)_ __ #dwells 0 Soil Boring(s) a of t7O""� 11 Geotechnical ISAO1r� 0 Out-0fservice Well ❑ Out-Of-Service Well Renewal 0 Corr Repair NVIR�U/N ECO 0 New Pum 0 Pum R 0 Pum R 0 Raise Well CasingALTy p LAMENT UN Y W ;Ix com" UCTM ME Drilling MM hld IKM W Rotary 0 Air Rotary ❑Auger Cable Toa ❑ Push Point ❑ Other Proposed Wig Depth ft Excavation In diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter ❑Conductor Casing in diameter / Conductor Casing Depth ft Wed CasIM Diameter�in ThickmwGauge(ASTM Sched� 0 steel Plastic 0 StaiNess Steel ❑ Other GrwR Seal Depth ft 0 Neat Cement(941b bag(5.10 gat water) ❑ and Cement sack mW7 gal water Berttorrte 20%solids) ❑Other Grout Plaimnwallethod XPumpod ❑ Free Fail 0 Ogler 0 Retardant/Accelerator(name) PWWA4 YwaW By 0 Driller 0 Pump Contractor 0 Other ❑ ConcrMe Pedestal ODknenslorm:Width ft Length it Thick lin ❑ Chrbty Box 0 Stove Pipe EM ❑ SubmersUe❑ Turbine 0 Other HP Pump Set ft Standing Water Level It Plot Plat Requirements: Attach a plat plan with the exact location of water well with respect to the following items: GPS Coordinates, property lines, adjoining properties, water bodies or courses, drainage pattern, roads, existing wells, structures, potential sources of contamination,sewers or private disposal systems. Include distance from two property lines. For Domestic, Agriculture,Industrial weK provide location of any water wells or surface water within 200'radius of proposed well- MINIMUM 24 SOUR ADVANCE NOTICE REQUIMED FOR INSPECTIONS-PLEASE CALL(209)953-7697 DEPARTMENT U_SE ONLY �- �� Date / �� „? Area S /�i Employee ID# pwpi ey Grout Inspection BY /6,�,s! (� z4� r Date r//3/ Z ❑ SPEctAL Well Permit PUrnp Inspection By Date ❑ WAIVER Received Soil Boring Inspection By Date Cansttuetad well Depth l tt A� s arc. t�OMMENTs exec�1' 'ye �+C' FY d✓ -.7—�u7 ( 0,2112 J'rII� E j? }F pu'�yt� .S :N< 's,�S'C_ s J 7 o4"l -ALJ- 11 tV 2 3 PE Sc Retatiwd Cho" Amount Dabs PWMW Invoices Well W# Codes Info By_ Cash Raniew Service Regmst# ElIDD4346 OWfAn Paw 1 ort Web/PunV Perndt l�f S75"_7