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of � f 1 WELUPUMP PERMIT SAN JoAQtm Coam EmvwowrewTAL HEALTH DEPARTUENT 1888 EAST HA2ELTON AvEm)E-STOCKTON CA 95205 -(209)488-3420 NON•REFtMOAKE PERMIT CALL 209 953-7"7 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS enc C.IZl CRM SITREE T APN 203-O N- a 16 PARCEL SIS�LLa o USE AMLICATtOw� q OWER NAEnYf) PHONE 2 OW,WI ADOwEasLljj� U arY/sTATElLP 9 53 CO CON►RA.Tm HayJlb PY11100PRONE ? -10)27-- II q21 CONTRACTOR ADDREss AibeCirr/STAW ZIPS t SUBCONTRACTOR PHONE SUBCONTRACTOR Aooms9 CrTYMTATEMP LICENSE C-57 0 CS1 O D-W ❑DOW *Menlfl — EvveATION DATE D Z DowEamc WELL SAMPLnG:(If General Mineral/ColHarrn Bacteria(4391)❑Dlbromvchloropropane(4392)11 Arsenic(4393) INTENDED last1KDorrwstkJPrtvate ❑ rrigatlonlAgricd Mal 0 kAnhial 0 Water Quality Mortoling 0 Soft SamplingtCharadertzatlon 0 Pubic water System It Mment tom Omer waw%taem Nana Co ad Naarie or Pham Nu Ow jYK OF WOtnk vNew Weil ❑ Replacement well 0 Well AllierationlModification ❑ Other ❑ MonkorkV Well(s) M of weft ❑ Sol Bod g(s) w or borings ❑ GeOkK tvrical Por twangs 0 Out-01—Service Well ❑ Out-Ola-Service Well Renewal 0 Cross-Co necion Repair 0 New Pump 0 Pump Replacernent ❑ Repair 0 Raise Well Casing WRL COwiTftxT M Drilling Metiwd 0 Mud Rotary n Ah Rotary 0 Auger 0 Cable Tod ❑ Push Point ❑ Other Proposed Well Depftt -(On ft Excavation_ t2 in diameter ❑Open Bottom Gravel Pwk ,ravel Sae in diameter ❑Cor>du Ca4kig in dfarrie/ar ! Conductor Casing Depth R Wadi Casino Diameter ,u in Thickness 3augWASTM Schad 2-00 - ❑ Steel KPiestic 0 Stainless steel ❑OCrer Grout tial Depth ZO O ft ❑Neat Cement(84 b nag(5-10 gat water) 0 Sand Cernent sack mora gal water lite(20%solids) 0 t3ltter (;routWIFwd Purnped 0 Free Fall 0 Other O Retardant I Accelerator(name) RAYAdrzhur InafaNd By ❑Driller 0 Pump Contractor ❑ Other ❑Conc rets Pedestal❑Dbasrnions:Widlh It Length It Thick lin 0 Chrlety Box 0 store Pipe "ZL7z-- 1ILLM ❑SubnwwsbeC Turbine ❑O0w HP Pump Sot ft Stallding WatP.r' ouiy rou iv ft PW Plan Regdre®ab: Attach a plot plan with the exact location of water well with respect to the f0U*MMg'4tNftr. GPS Coordinates,property does, adjoining properties,water bodies or courses, drsiaaSe pattern, roads, ezistiaB welt, structures, potential sources of contamination,sewers or private disposal systems. Include distance from two property Hues.For Domestic, Akgricakare,Industrial well,provide location of any water wells or surface water within 200'radios of proposed well- M MMUM Z4 HOUR ADVANCE NOTICE REQUIRED FOR INSPEC ]IONS-PLEASE CALL(209)953-7697 DEPARTMENT US ONLY L/ p Application Accepted By Date o 22 Area / / Employee IDMr Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAim Received Sot Bari„ Inspection By Date- Construclad Wea Depth R COMMENTS PE SC Rscalvvd Check& Amount Dad Iwvoica/ Wali wo Codes Into ev Cash Sarvioe RequNd 0 70 0 0 Z `/ S (iewli 4 \/ CD I{ 8 EAo.ws owrrmn Z Z ( 2 Weil rasa Pani