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WELL/PUMP PERMIT SAN JOAouii COUNTY ENvmNMENTAL HEALTH DEPARTMENT 1868 EAST HAzELTON AVENUE-STOCKTON CA 95M -(209)4683440 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED se -1 KJOB ADDRESS G Ctnr1ZIP r�ry CROSS STREETvine AP 253`1� 11L PARCEL SIZE LAND US PLICATION# D OWNER NAME v --- PHONF r' t 0,M ADDRESS _PO2WYJCRYISTATEIZW CONTRACTOR MASELUS DRILLING INC. PHONE 209-522-1928 CONrRAcToR ADDRESS 119 ALBERS RD. CffyrSTATEIZIP MODESTO,CA 95357 SUBCOINTRACTOR 1� PHONE SUBCONTRACTOR ADDRESS CrTY/STATE/LP LicENw )Q C-57 ❑ C-61 0 D-09 n Other Nuke" 668622 ExmATm DATE 04/30/2023 DorEsnc WELLSA•tPLOG:❑General KneraLCAform Bacteria(4391)ErDibrornochiorvpropane(4392)Lt Arsenic(4393) -4 brroM USE ❑ DomestidPrivate kr0*orVABrtr11ral g Industrial ❑ Water Quality Monitoring U Soil Sampling/Charactenza C FF T n Public Water System D If dBerent from OMM Weber System Name Cmtat3 Name or Phone Number TYPE OF W 19!4—well ❑ Regtac mer*Well ❑ well AltBratimfMOdiftatim ❑Other p ❑ MonibykV wea(s)_ #of wefts 0 SoN Boring(S) a of eonngs ❑Geotechnical �- 1 U� 0 O�f�ervit: WeM o Out4) Service Well Renewal Q Repair NFALT �O�N�M�ND TY ri Pump R—"r Raise Wei Casing trlrf,.,.Cor•srxuryn4N r DdINng Modwd][Mud— ❑Air Rotary ❑ []Cable Tod ❑ Push Point n Other Proposed well -p�1�fh t ft Excavation in diameter R Open Bottom Gravel Pack/Gravel Size in diameter ❑ Caskg in drarne6er Co Depth ft Wall Casing D inThWm9es/Geug8/ASTM Sched� n Steel Plastic ❑ Stanfess Steel a Other Grout Seal ft ❑ Nest Cement(941b bag'5-10 gal water) ❑ Sand Cement Sack mkR gal water jneenterrte 20%golds) ❑Other Grout- --- srrt Pumped 0 Free Fall ❑Other ❑ Retardant/Accererator(name) iAL k I Nid By 0 Driller ❑ Pump Conbac Dr ❑ Other ❑ Concmb PedmW❑Dlrnooslonr Width ft Length ft Thick in 0 Christy Box rI Stow Pips PtatP 0 Submerslbao Turbine 0 Other HP Purr, Set ft Standing Water Level ft Plot Plan Requirements: Attack a plot plan with the exact location of water well with respect to the following items: GPS Coordinates, property Imes, 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 tines.For Domestic, Agriculture,Industrial well,provide location of any water wells or surface water within 200'radius of proposed well. MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-n EASE CATS.(209)953-7697 DEPARTMENT USE ONLY �J Application Accepted By �� L Date o? O/ o?.Z Area S �! Employee ID#_ Grout Inspection By r Date ❑ SPECIAL.Well Permit pip Inspection By pate 11 WAIVER Received _ Sol Barg Inspection By Date Constructed Well Depth COMMENTS HP.1 12eirrvylt re +ie r Um r ravl M4 I V belwl?07o a:;o' eel. (C'0-5 penal Codes Info Received C�Cash Rernttt d Servic Date e s Invoke ar well IDS 37s JF0 -S11 EI M041-06 04107rl= ( P.W 1 of 2 Wc11/Pump Pcni