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WELUPUMP PERMIT <br /> .RAN JOAOUIN COLRrrr ENVIRONMENTAL HEALTH DrPARTM(NT I e68 EAST HAZELTON AVENUE•STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ANDRE55 5`�q C� f J(�1 c n j, Q <br /> GTYrzIP 5�.---. I 9 tp32 —. m <br /> IIIt�S°j STREET �_.__�I/,J AoPN Uy�5-If 'i(QD W pARC£L 512E 0' LAND USE A/�PPI 1CAT30N l/ __._._ OP <br /> CIWNER NAME ^.�a-'_.1 ,.�1... �-t .M aft-)c PHONE. `f I(D CCOZ Yn <br /> i {?OWNER ADDRESS � i-ai-1 1rYf_ __. Cm/STA //ZIP— -11 t---1� g,rJIr,,2— <br /> �7 <br /> PHONE _(q I05L r+00(0 <br /> r_r"ISTATcf7111' Id ItD 1 I CR 95i-I=� <br /> F iSt1BCONTRACTDR -- _ PHONE <br /> (SUBCONTRACTOR ADDRESS -- _. CITYISTATE/ZIP <br /> j ILtCENSE k'C-57 C-Fl D-09 Other __ NUMBER-�1 Il J�_ EXPIRATION DATE___D1� <br /> i DOMESTIC WELL SAMPLING: General Kneral/Coliform Bacteria(4391) Dlbromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE }CDomesticrPnvate Irrlgation/Agricultural ' Industrial Water Quality Monitoring ' Soil Sampling(Characterization <br /> Public Water Svstem _.------.—___---___-- <br /> II r60f-mn from Cvwne Wow Syswn Name Como Name or Phone Numbet <br /> TWE Or WORK %,New Well Replacement Well Well Alteration/Modification ❑Other <br /> Monitonng Well(s) #of wells Soil Boring(s) Iab°rl"95 0 Geotechnical eofbe" <br /> Out-Of-Service Well Out-Of-Service Well Renewal 0 Cross-Connection Repair <br /> ?XNew Pum- Pump Replacement Pump Repair 0 Raise Well Casing <br /> WELL CONSTRUCTIOr. - <br /> Drilling M thod X Mud Rotary Air Rotary Auger Cable Tool 0 Push Point 0 Other <br /> Proposed Well Dept '•Q(_it Excavation in diameter 0 Open Bottom XGravel Pack/Gravel Size_in diameter <br /> COndUCtOr Casing in diameter / Conductor Casing Depth It <br /> w:*11 Casing Diameter-12 in Th;ckness/Gauge/ASTM Sched sbiZ zI_ 0 Steel XPlastic 0 Stainless Steel Other <br /> Grout Snal Depth 200 ft Neat Cement(94 1b bag/5.10 gal water) k mall gal water <br /> X XBentonite(20% Other <br /> Groin Placement M kkad)C Pumped Free Fall Other ❑ Retardant I Accelerator(name) <br /> Pf: w2- Installed By )C Driller Pump Contractor ❑ Other <br /> k Concrew Pedestal Dimensions:Width > It Length It Thick r' <br /> Chris.:y Boa Stove Pipe WAY 14 2;1 <br /> -. -__.__.__-.....-_— -- <br /> Pubw h Submersible Turbine . Other HPPump Set D It Standing Water Level <br /> Plot I'lar, Requirements: Attach a plot plan with the exact location or water well with respect to the followir, " L <br /> 0i,ordivalm. priTrrip lines_ adjoining properties, water bodies or courses,drainage pattern, roods,existing we114,!E:A+tl+ttit�tlh't�SE" <br /> potential wurf ce of wntalilination, wwers or pris ate disposal systems. Include distance from two property lines.For Domestic, <br /> Agriculture.Industrial M ell.providr locatiou or any water wells or surface water within 200'radius or proposed well. <br /> M3,I'll( .LI.'A tial R.nLN %N( I *,OTT4'K RI:UI'IILI:D FOIL INSVI t-I10,S.PLEASE CALL(2091953-7697 <br /> DEPARTMENT UX O LY <br /> Ayyplicatlon Accbptbd By �iSr Date � Area / !,_._. . Employee ID# '/ <br /> Gruut Inspbct,on by Date 6 SAN Zo' SPECIAL Well Permit <br /> Pump Inspncbun by Data _ —_ WAIVER Received <br /> Sod holing Insuvcuon by \t' \ Date Constructed Well Depth N <br /> COMMENT S�Y!" A_%A \) <br /> - - - - <br /> i—'— SC Rocelvad ChfackN/ Amount - Permit) <br /> I Oat Invoice N Well IDN <br /> Codes i Into i 8 I cl Rvm <br /> ltted Service Request N I <br /> _-- ` <br /> X70 _/ir <br /> o V �Zo 1 y WP004404Z__ <br /> 1/38'01 0-51 I s-Ip 1 W P 00+4 0 4 8_ <br /> /Ss �� WPoo4404-7 <br /> — — _— <br /> y39� 7& .W-p <br /> 11119111 Ir-111111 211•.• 1.,...t .l' w'cll/{'u 11Trrrii <br /> �s2 - 1 , <br /> D 2� - LV5� �'-1 -� �� kms. <br /> �S li 3 �sl 12(�� <br />