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- <br /> ' NOV 15 2022 <br /> 1 �Y. WELUPUMP PERMIT <br /> SAN JoAotm COUrm ENvtRONMVrrr L HEALTH DEPARTMENT IM EAST HAzEToN AVENUE-STmKTON CA 95205- (209)4U-3420 <br /> NON-REFuNDAEU PERU r CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> 12�7 <br /> Joe ADDRESS cmrrzr 2 g <br /> CRoss STx>EErHahoh Pd. APN 'V !U f �J PARCEL SRe U5W}o USE Aa�tc�tnoN# 4 <br /> OWNER NAME PHONE — E! <br /> �fi <br /> 95 9101 <br /> OWNER ADDRESS I t9to I IJ CtrYISTATFJZIP kn'-� <br /> CONTRACTOR �j' •n }PMOry`NE �!l'! Iµ52) 1 2! J <br /> CONTRACToaADOREss I CmJSTATdLP T t��I�(l,IIJ c' 1 <br /> SUBCONTRACTOR <br /> SUBCONTRACTOR ADDRESS Cir1rISTATEIZ1P <br /> LICENSE 7 ❑ C-61 ❑ 01-M ❑ Other NUMBER EXPIRATWN DATE <br /> DOMESTIC WELL SAMPtnia:gGeneral Min&ml!Coliform Bacteria(4391) Dibronnochllx pane(4392)n Arsenic(4393) <br /> INTENOEe Use jf�D«nest)df'rivate ❑ IrrigaiioNAgricultural D Industrial o Water Ouatity Monitoring o Sol Sarnplin9CCharactenzation A <br /> ❑ Public Water System <br /> A le <br /> n ditrent from owner WSW Sydwn Name Contact Name or Phone Number I <br /> TYPE QF WendtNew Well ❑ Replacement Well ❑ Wed Akeration/Moddication ❑ Other IC <br /> ❑ Monitoring Well(s)�#of weds [I SON Borings) #°r b0O"� D Geotechnical s°r O <br /> ❑ Out-Of-Service Well a Well Renewal n Cross-Connection on�Repair S4 A/JC ` <br /> ❑ New Pu a d Rt [I Pump Repairise WON <br /> R <br /> q rH D p44EN r Tv 7y <br /> Dill"Method P(Mud ❑Air Rotary ❑ Auger Cable Tod ❑ Push Point D Other <br /> Proposed Well DE ft Excavation in diameter ❑ Open Bottom XGravel PacidGravel Size in r <br /> ❑ Conduct Casing in diameter 1 Conductor Casing Depth ft <br /> Well CasingDiameter in ThidknesslGaugeIASTM Schad2zo _ ❑ Steel Plastic ❑ 5tairdess Steel ❑ Other <br /> Grout Seel Depth ZOO ft ❑ Neat Cement(94 lb beq(5-10 Qat wafer) ❑ Sand Cement sack mbJ7 gal water <br /> KBentorAe(29%sold.) D Other <br /> t3rourt PlacemiNd Method XPumped ❑ Free Fad ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDMAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal❑DknertskKw:Width ft Length ft Thick <br /> In ❑ Christy Box D Stow Pips <br /> lam D Submersible0 Turbine o Other HP Pump Set It 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 trines, 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 limes. 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 /> D PARTMENT USE ON Y �/ <br /> Application Accepted By Date O/ 2� Area i Employee ID#� <br /> Grout Inspection By Date I ' ❑ SPECIAL Well Permit <br /> Pump Inspection By Date U WAIVER Received <br /> Sol Boring Inspection By Date Constructed Well Depth R <br /> COMMENTS <br /> PE Sc Recelved Chsckl/ Amount Dab PWMIII Invoice# well NV <br /> Codes Info BY Cash # <br /> 3 D </ <br /> SS <br /> to <br /> �p�y.p6 p�grgp� Pw 1,A2 Well I Atnq Penet <br />