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X WELL/PUMP PERMIT <br /> SAN J4AouN C4um ENvNaQNmwAL HEALTH DEPmnT'k ev 1863 EAST HAmi.ToN Avewr:•SrocHTou CA 85205-(209)46"20 <br /> I+ION-Rl<FIINDABL.E PERMIT CALL 209 963-7$$7 FOR INSPECTIONS EXPIRES Z YEAR FRom DAte Issurm <br /> JOB AaoMss <br /> CtTYIZ p ES--4 Lo ifs <br /> I ���� <br /> CROS&STREETms) r�j 1 kY t APN L0 3-AIQ -OS7?ARGa$gE�Ct #�USEAYPLICATtON# <br /> OWNER NAME DA t i` ll lkta W L l am} err .� �► Px[NE!9-q Uq- <br /> OWNER ADnRESs 4� L n„y+• r--r ►G 4C - QTYISTATE121P L <br /> CONTRACTOR r A_1ts-C &&� .. Il iL l i a)l 12L Iup PHONE 2,01 <br /> Coff CTOR AOoMSS 2-46e.> CITYISTATEIZIP v++-14) ,f, -Z. <br /> SUSCOMACTOR PHONE <br /> SLIBCONTRACTCR AoOaESS CITYISTAW <br /> LICENSE ❑CS7 C$9 ❑D-09 ❑ Diner NUMBER EMRATIONDATE <br /> DOMESTIC WELL SAmpumn:Q General MineraVCaliform Bacteria{4397}❑❑ibromochloroprpparte(4392)Q Arsenic(4393) <br /> INTENyeO Use ©DorrestidPrfveAa XlrrigetbnfAgricultural ❑Industrial 0 Water QuatiSy Manitgrg 0 Soil Sampk WCharacterustion <br /> 0 Pubic Water System <br /> frdAvarA koro Owrmr. Wader System Nerve Corded Nome or Phore Nrxrber <br /> --'TYM DF WoRA 'slew Well 0 RepfaceHlerrt WO 0 Well A1te1'8tiMVW)0diF1Catlon ❑ Other <br /> 0 146orriloring WO(s)_#of yetis ❑Soil Horing(s) a°t b5rN5 ❑Geotechnical. >r ofbxtn b4 <br /> 0 Out-of-Salim a Weil ❑ Out-Of-Service(Nell Renewal E Cross-Connection Repair ^I� �+ <br /> Pdmp o Pump Re lw-eimesil 0 Pump Re Ir ❑Rake Well Ga3ing <br /> WELL.CCN5TRUCTKMIll <br /> ❑rifling Method ❑MA Rosary ❑Air Rotary 0 Auger 0 Cable Toai 0 Push Paint ❑ Other I A <br /> Proposed Well Depth R Excavation In dlameter 0 dpan Bottom 0 Gravel PeckiGravel Size in dlsrn <br /> ❑Conductor Casing is diameter Conductor Casing 0ep@i ft FNIrjR�CI)N <br /> Wed Caskng Diameter_ In Thlckness1Gauj iVASTM Sc7red. 0 Steel C Plastic ❑Stainless Steel ❑�� N N� <br /> Grout Soil Depth ft ❑Neat Cement(941b bWS-10 gal wafer} ❑Sand C mnard sack m! <br /> C Bentonite(2011D solids) ❑ahts N� <br /> Grout Placement Method 0 Pumped 0 Free FaS ❑Other _ ___ _ ❑ Retardant i ACCM"tor(name) <br /> PEDESTAL Installed By ❑GrUler Pump Contractor VE Cnher <br /> It Concrete Pedestal 1001merlsions:Width��h LanglhIt�h ���� <br /> In L Christy Sox ❑ Stave Pipe <br /> uftP G Submwslbla TurNne ❑Other HP C Pump Set­2,b—*L-fl Standing W9lerLeyel-Sd tt <br /> Plot Plan Regtdremenu, Attach a plot plan with the exxcl location of water well with respect to the fallowing Items- C.PS <br /> Coordiaales, properly lines, adjoining properties, water bodies or courses, drainage pattern, rods, exhting wells,structures, <br /> potential sources of contanOnstion,sewers or private disposal systems.Include distance from two property linea.For Domestic, <br /> Agriculture,Industrial well,provide location of any water wells or surface water within 206' radius of proposed well. <br /> KI[INITMUNI 24 HOUR ADVANCE NOTICE REQUIRED FOR L[SPEC71ONS•PLEASE CALL(109)953.7597 <br /> DEPARTMENT USE ONLY <br /> Apptiration Accaptod 13y Dote c�«� Area ErnplNae ID# A <br /> Grout Inspection By_. Date D SPECIAL Well Permit <br /> Pump Inspection By — Data a Z---' D WAVER Received <br /> Sod Boring Ins on By Date Conslamtad Wall Depth R <br /> COMMENTS IF rn+ Lr- <br /> PE SC Received Check#/ Amount Date Permitf tnvoicr S Well Ilan <br /> Coates info a Cash Remitted Sarvlca Re vest 0 <br /> "438,Q —0:5,I isg <br /> rHDD43-M to UMI PW 1 era Neal l hop Penn <br />