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1 WEWPUMP PERMIT <br /> SAN JoAQuw Comm ENvRONmENTAL HEALTH DEPARTnENT lea EAST HAZELTON AVENUE-STOCKTOON CA 95205 -(209)468-3420 <br /> NON-REFUNDABLE PERMIT C�(�nALL 209 w <br /> 9 7697 FOR bAPEC� Ns EXPIRES 1 YEAR FROM DATE IssuED <br /> JOB ADDRESS It, C[rrrm C. 5 54 <br /> CRw-T 9 0 Io3S S? APN 1 C'_�? )�U J <br /> _ 'ARca SPE aL—L,.D USE Am"Tiom#,� � <br /> OWNiER NAE Pyn A IPHohE 209-�1 g -5 07 p <br /> OWNER ADDRESS U I 1A 1p Li Rd m,mATErz.-� --17)n9626Q <br /> cow,wACTOR /;► PHONE 2(J"1' —622—I <br /> CONTRACTOR ADDRESa "1 CITvl3TAT150P/"4n n � <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS c n-YYISTATErhP <br /> UcENSE C-57 n C-61 0 D-09 ❑oa>e� Nuns,, U/ E P wrT.DATE <br /> DmEsTlc WELL SAMPLING:i�General M'rteraUCo ftm NxwiochioroProPane(4392) Arsenic(4393) <br /> INTI mw USE Dome9IC/1-rivn1e O trrigistionlAwicult ral 0 Industrial 0 Water Quality Monitoring 0 SON SampinglCharader¢ation <br /> IF❑ Waw System <br /> W d moil ion Own Warr SYNWM home Contact Mom w Phone Nlrnbw <br /> TYPE OF WORT �Iew Well 0 Replacement well 0 wen AlUeratiMModilicstion ❑ Other <br /> 0 Mordarirg Weg(s) N of well 0 Soil Bork*s) s of bminp ❑ Geoiechnicel 0 of b=W <br /> U Out-U-Service Well ❑ Out-01-Service Well Renewal 0 Cross-Connection Repair <br /> ❑ New Pump U Pump R ent ❑ Purnp Repair 0 Raise Well CasIng <br /> WELL CONSTRUCTION <br /> DrilHW Method/y�Mud Rotary D Air Rotary 0 Auger [�Cable Tod 0 Push Pant 0 Ottter <br /> Proposed WeN i�D�epth _ft Excavation _in diameter 11Open Bottom ❑ G Pack/Gravel Size in diameter <br /> 11 Conti or casing in diameter I Condo Casing Depth ft PAYM NT <br /> Well Casing Diameter In ThicImeWGaugeIASTM Srhed= 0 steel Plastic 0 Stainless steel ❑other EQ <br /> Grout Seal Depth�ft ❑Neat Cement(941b beg,5-10 gar water] 0 Sand Cement sack mixl7 gal <br /> ❑ Beniani (20%acids) 0 oft. <br /> Grout Plat:antard Medwd 0 Pumped O Free Fag El Other <br /> Other 0 Retardant/Accelerator(name) 2022 <br /> POMA lM�d ly 0 Drt�r d PuiTip ContractDr ❑ Otho ENVIRUMr ' <br /> L'slOdtllts `ion PAR 1. <br /> lin 0 COffrlab Pedestal❑DIInMraiOrM:Widlfi ft Length ft Thick ENI <br /> 0 Christy Box Cl Slow Plpa PAY <br /> P m 0 SubmersibleO Turbine ❑Ogler HP Pump Set ft Standing Water L ft <br /> Plot Plan Requirements: Attu* a plot plan with the exact location of water well with respect to the following items: CWIS <br /> Coordinates, property tines, adjoining properdM water bodies or courses, draiu ige pattern roads, existing g[* <br /> potential sources of centamioatieo,sewers or private disposal systems. Include distance from two property lines For DoMIRS <br /> Agriculture,Industrial well,provide location of any water wells or surface water within 2911'radius of proposed AQ01N COUNTY <br /> l HEALTH DEPARTMENT <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(269)%3-7697 <br /> �--�7 DEPARTMENT USE ONLY <br /> Application Aooepted By `L L- Date � a a a Area L)/ Employee IDR C� <br /> Grout irspection By Dare 0 SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAA R Received <br /> Sal Boning Inspection By Date Consbuctoed WON Depth ft <br /> COMMENTS �> t(>1c Mlel to be P5 1>�✓PGry1? /r� Pt?✓rn r)� Spy rGl�e 1DumU pt-r1vlr >� <br /> iS 1L�4�I�INL <br /> C d a 9C R�cal�ad Cho ddf pie Tf%W * Invoice i WON IDN <br /> boo Ib .1 Service Request70 D r381 3 <br /> 439 1 4 -76 <br />