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I WELL/PUMP PERMIT <br /> SAN Jo AUU1N COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAMTON 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 ADDRESS 104U6. VE SoAhlad. ILOL CmJ�/1JP / 'A1t• Ug% A <br /> � ek 7 M(. <br /> CROSS STREET 1��suw APN 7A B -C7�-z�_ PARCEL Baa LAND USE APPucAnoN# x <br /> OWNER NAME �Y�M^ Ga dt"i,nt <br /> � 'A Pw**(� ) <br /> OwNMADDREss 3 8 is_ kif nit} 1A3�� C"MTATVZP At-1 et!q � I? <br /> CONTRACMR MUIS at-I PHONE Ts 2Z- t-I 24a <br /> CmmtAcToR ADDREss IM A Lbtrs Crnr1STATE ZP M*d''S t4'. r n AS�S7 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATE&OP <br /> UCENSE YC57 ❑ C-61 ❑ B-09 0 Other NuMaER 6kb&2Z2 EMRATION DATE 14 <br /> DOMESTtc WELL SAAMPLatG:C General Mineral/Coilforrn Bacteria(4391)0 Dibromochloropropane(4392)G Arsenic(4393) <br /> INTEHDEn USE 5DamesWPrivale ❑ IrrigationVAgric;uIltural ❑ Industrial C Water Quality Mordoring ❑ Soil Sampbng/Characterization <br /> o Public waiter Symern <br /> M diatom d+ae Chmer. wow Syalam Naar Carred Name or Plane Number <br /> TYPE OF WORK :,New Well K.Replacement Wed ❑ Wei AlteratiorllfiAodirlcation ❑ Other ICI <br /> 6 Monitoring Wad(s) #Of wens O Sod Boring(s) r of b wing ❑ Geotacimical r Ih m, n <br /> V Cc <br /> O Out-O Service Wed ❑ cut-OfSerAce Well Renewal 11Repair /��t ' 9 <br /> O New O 0 Pum 0 Raise Wel S ?02[ <br /> Drilling Method�Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Toot ❑ Push Point 0 Other HFALTHRONMFN UNT <br /> Proposed W.II Depth Z8`0 ft Excavation 1,7- " in diameter 0 Open Bottom V Gravel Pack/Gravel _�JlnWWiilll <br /> in <br /> 0 Conductor Casing in diameter / Conductor Casing Depth ft <br /> Wes Casing Diameter j in ThcknesslGau0ASTM Sched 24,4P 0 Steel XP4astic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth Zoo ' ft 0 Neat Cement(94 1b beWS-10 gal water) ❑ Sand Cement sack mbd7 gal water <br /> B6mtonde(20%Sol&) ❑ Ofher <br /> Grout Placer will MedwdX Pumped D Free Fall O Other 0 Relartlant/Accelerator(name) <br /> PEDESTAL k*hdW By 0 Drier 0 Pump Contractor O Other <br /> O Concrete PerMetal ODdrrenslons:Width ft Length ft Thick <br /> in 0 Christy Box 0 SWve Plpe <br /> ltym O Suhrnersibie0 Turbine 11 Other HP Pump Set ft StarW"Water Level ft <br /> Plot Plan Requirenwats: Attach a plot pian with the exact location of water well with respect to the following items: GPS <br /> Coordinates, property flees, adjob ing properties, water bodies or coarses, drainage pattern, roads, existing wells, structures, <br /> potential sources of contamination,sewers or private disposal systems. include distance from two property lines.For Domestic, <br /> Agriculture,Industrial weII,provide location of any water wells or surface water within 200'radius of proposed well. <br /> �II\I il ) Ia 14kI1 R 11 E♦+illi t hlk.Qt-IREV P(19 t\>r't'( 110%%-PLEASE(.►LL.(2119)951--,69` <br /> DEPARTMENT USE ONLY ) <br /> Applicat `�ion Acospled By Date 11 Area `I / �I Employee ID# <br /> Gran Inspectlon By Date ?j2 O SPEcmi-well Permit <br /> Pump Inspection By Date 0 WAIVER Received <br /> Sod Boring InapedioTt By <br /> Date Constructed WeN Depth Uy n <br /> COMMENTS <br /> PE 9C Received Check/ AnKxud P0 Invoice alt Was I00 <br /> Codd we am, Cash RsEnIMdPill >lNv10a alR <br /> 170 0 4`1010 IZ , <br /> -01 If/670 <br /> 139 b <br /> �„ n Well I Pump tk.m: <br />