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Y <br /> 1 <br /> 1 WELL/PUMP PERMIT <br /> SAN JoAo4m COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)4683420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTHM EXPIRES I YEAR FROM DATE ISSUED <br /> .toe ADDRESS _ b Gt k crryrzjp M�,I,ntP ccs 9 5&3(o 5 <br /> B <br /> CROSS STRT APN 2+ 6-.N r� !2 PARCEL SIZE 1�y .1WD USE AP}PucAT ION#/�, <br /> OWNER NAME PtrONe 1 20"1 (tJ rU(3� <br /> Ow.WRAOMIM 19200 5, MAO-' Ta M R A CIWSTATE,Zl M Gj n ff ctl Jr,)36(0 <br /> t <br /> CONTRACTOR H {�'11is [) ii llina ('�• PHONE <br /> 20 q-522- 192'9 <br /> ColrrRACTaR MO EES l I I JI,f s 1\L/l - CnVSTATFllP�/1 Q f <br /> SUITOR PHONE <br /> SuscomTRAcTOR Acimrm C"VSTATE/ZIP <br /> LICENSE V C-67 ❑ C-61 0 D4)9 ❑ Other NumsER (010 EVIRATION DATE <br /> DOMESTIC WELL SAMPLOiG:i;General MineralfColiform Bactefiil(4391)'j Dibrornochlarepropane(4392).-:Arsenic(4393) <br /> htTEM XD USE ❑ Domestic(Pnvate XimortioniAgricultural ❑ Industrial ❑ water Quality Monitoring 0 Soil Sampingla-racterPbn <br /> ❑ Public water system _ Yn n.�_ <br /> It a6era t from Owner. Wafer System game Corxad Name or Phone Nuriber <br /> arz- <br /> TYPE OF WoRK New Wer ❑ Replscernent well ❑ well AkeratimWodffication ❑Other <br /> ❑ MonkodN Wer(s) #of weft ❑ Soil Bohng(s) 0 a b-Inp 0 Geotadriirali °t,6vr ` <br /> El Out-Of-Service Well ❑ Out-Of-Service Well Renewal u cross-Connection Repair Sq V GC 2022 <br /> ❑ Now Pun ❑ Pum t El Pump R it ❑ Raise Well CasingN✓O <br /> WELL 2MEM&1!5M HE;- , I , C <br /> tiiMhod)(Mudn R Air ❑ r Cable Tod Cl Push Pant ❑ r <br /> Proposed Will Depth_m ft Excavation��in diameter ❑ Open Bottom qkGravel Pack/Gravel Size in diameter <br /> ❑Con"Artirr In diameter / Cord Casing Depth ft <br /> VM Caslnp TNda>aw/GaIKWASTM Scued ❑ Steel Plastic Li Stainless Steel ❑ Othw <br /> Grout Baaliv ft D Neat Cement(94 Ab be915-10 gal waW a Sand Cement sack nk[7 gai water <br /> �EiWiorltm cords) ❑ Other <br /> GmA Ptacsment` Osgood XPLAmped ❑ Free Far ❑ Other ❑ Retardant/Accelerator(name) <br /> SAL Instated By ❑ Drier ❑ Pump Contractor ❑ Other <br /> ❑Calcis"Psdesdd❑Dbrlstlsions:Width ft Length ft Thick <br /> in u Christy Box ❑ Stow Pips <br /> ❑ Submersible❑ Turbine ❑Other HP Pump Set ft Standing Water Level ft <br /> Plot Plan Requirements: Attach a plot plat with the exact location of water well with respect to the following items: GPS <br /> Coordinates, property lines, 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 l sim 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 /> DEPARTMENT USE ONLY <br /> Application AccepUod BY .vim'ef f l Date t _ Area S d! % Employee ID# <br /> Grout Inspection By Date 0 SPEctAL Well Permit <br /> Pump Inspection By Date 0 WAIVER Received <br /> Sofa Bortug Inspection By Date Constructed Wall Depth ft <br /> i - - nn i f C,i1�. U 9t- <br /> )6 <br /> - <br /> G� /"„" /2" (o"e, 1411111ZLA"" of <br /> PE <br /> 3C R ChscklN Amount Dab PWMWlmoia# Well ID# <br /> Codes Mry <br /> Moo Cash RwnNbd 8slos # <br /> 3s�; � MIX&L <br /> r111*43-06 kwmrzon Pw I ere r0CJ�` 2 ((6J Zq � , win,r,o�e�.r <br />