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1 WELUPUMP PERMIT SAH JOAQUIN COUNTY EWARONIMENTAL HEALTH DEPARTMENT 1888 EAST HAZELTOH AvENUE-STOCIkTON CA 95205 - (249)4683420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED Jos ADDRESS CITY/ZIP m Awn l �lsal5 D SS CROSTREET �. I APN PARCEL SIZE LAND USE APPUCATION# Iryon OWNER NAME PHONE G W OWMER ADDRESS ' �] `v CfTY1STATEfZIP (SIX 7,71j. ] �]' V'7 COIrrRACTOR 1 1 � �C � P�} c Lam"i CONTRACTORAuow- CRY/STATE/LIP 1 r1Y u J�C4 ] SUBCONTRACTOR PHONE SUBCoKTRACTOR ADORESs CI TY/STAT&ZIP _ LICENSE kT ❑ C-61 ❑ D-09 0 Other NurrBEt MR 12— ExPfRAnow DATE DOMESTIC WELL SAMPLOG:C General MlneraVCodorrn Bacteria(4391)C_ Dibromochloropropane(4392)C Arsenic(4393) INTEN20 USE 0 Do1T1ee3tidPrivate krgatwVAgncultura! O Industrial ❑ Water Quality Monitoring 0 Soil Sampling/Characterization O Public Water System V dllarent from Owner. water System Nene Conrad Name or Phone Number TYPE OF want New well ❑ Replacement Wer ❑W.A Atteratior Modification ❑ Other ❑Mol'I tiring Well(a) S Of Wert O Sol Boring(s) a ell borlrW ❑ Geotechr" N of borings ❑ Out-Of-Servioe Wer O Out-Of-Service Well Renewal ❑ Goss-Connection Repair 11 New Pump ❑ ❑ Pump Repair ❑ Raise Well Casing WELL CO"STRucnol+ Drtlirry Yaltlod'A ❑ Air Rptary ❑Auger Cable Tool ❑ Push Point ❑ Other Proposed War Depth�ft F_ cavation in diameter ❑ Open Bottom Gravel Padk/Gravei Siz It in diameter ❑ CorxkNff Casing in diameter / Conduc �asing Depth fl War Casing Diameter in ThidkrwwJGauge/ASTM Schad 11 Steel Plastic O Stainless Steel O Other Grout Baal Depth ft ❑ Neat Cement(94/b bag15-10 gel water) Sand Cement sack mix17 gal water ❑ Bentoroke(20%soids) ❑ Other Grout Placeromd Madwd Pimped ❑ Free Fall 0 Other ❑ Retardant/Accelerator(name) PEDESTAL kosta6ad By O Driller O Pump Contractor O Other ❑ Concrete Pedestal❑DknensIons:Width ft Length ft Thick in ❑ Christy Box 0 Stan Pipe &&M 0 SubmersibleD Turbine ❑ 00w HP Pump Set ft Standing Water 4e 'nou r ft Plot Plan Requirements: Attach a plot plan with the exact location of wager well with respect to the folio j"iQbWEGPS Coordinates, property linea, 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,Lrdustrial well,provide location of any water wells or surface water within 200'radius of proposed well. �1-'4 H,;. i..%D\ANCI N.':I(.L HEC/',IKI : !(rP i :'L( '."'� i i E..1St't.\e.2.•,_'89:-r. ) DEPARTMENT USE ONLY App, By �� L Date j rJ 7 .? A� yG Empbyee ID# . GmA kspectio By 1 Date 2�1"� Z ❑ SPECIAL Well Pormit pump lnapecbon By Date O WAfvER Received Sod Boring lnspeCUort By Date Co*bmcted Wer Depth ft COMMENTS [Xe((. 1-iVe nrr'/OF1' �- 1-.�r� (`Gi`nPlic✓!t Sr pt' G��F' l�t'1 '�rf Yr'�;i'i✓?C' �-, r PE Sc Recehred Cho" Amount pffn" Invoice* Wer ID* Cads Into 'By, Catch Remitted Data Service ! EHD073-06 IP IS/?flQl �J � ✓ �� YJ � �°l� pne I of 2 WC11 I Pvry Y�