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of N MnQ__ .1 <br /> 1 WELUPUMP PERMIT <br /> SAN JoAouN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 -(209)4883420 <br /> WON-REFUNDABLE PERMIT p y�� CALL 209 953-76 7 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> J013 ADDRESS 1 l tt iM12 Rd CrrrILP i0on qfQo(VAq <br /> CROSS STREETRA - APN 2(�3-ON- 416 PARCEL SIZE.SSI_LAND�>;E APPLI�ATK�«# 9 <br /> OMSER NAME <br /> PHONE 7l +,_�3 31 r�3 <br /> OWNER ADDRESS rrmcp CootCRYMATE>ZP_�+ 953(D <br /> CONTRACTOR 1 n P���HTTTONE ' -52Z� ! 2 c� <br /> CONTRACTOR ADDRESS V Kid CITY/STATEhEr , - �J� <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYIST/A^TEMP <br /> LICENSE C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER (UMl!1, EXPIRATION DATE �� Z <br /> DOMESTIC WELL SAMPUNa:;[General MinerallColiform Bacteria(4391)❑Dibrornochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE DomestidPrivate ❑ IrrigaWWAAricultural ❑ Industrial ❑Water Quality Monitoring ❑ SoN SampfinglCharacterLmdon <br /> D Public Water System <br /> If dhTererd from Owner. WaW Sy%Wn Nana CorMad Name or Phone Number <br /> TYPE OFYV New Weil [IReplacement Well ❑ Well AlteratioNModWrAtion ❑ Other <br /> ❑Monitoring Weis) #of we0s ❑ Soil Boring(s) x of borings El Geotechnical #°r bOf1"o' <br /> ❑Out-O Service Well ❑ Out-01-Servioe Well Renewal ❑ Cross-Connection Repair <br /> ❑New Pump ❑ Pump Replacwnent ❑ Pump Repair ❑ Raise Well Casi <br /> WEti 922E R 191M <br /> Drilling Method ❑ Mud Rotary ❑Air Rotary ❑Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> proposed Well Depth_2(QOft Excavation _ t��in diameter ❑ Open Bottom f Gravel PacldGravel S¢e in diameter <br /> " in diameter / Conductor Casing Depth ft <br /> m <br /> Well Casing Diaete \11 <br /> r n T <br /> hidme>;s/C,au0ASTM Schad 2—on ❑ Steel K'Piastic O Stainless Steel ❑ Other <br /> Grout Seal `L o O it ❑Neat Cement(94 ib bag(5-10 gal water) ❑ Sand Cement sack mar17 gal water <br /> (20%solids) ❑ Other <br /> GroutMedrod Pumped ❑ Free Fall O Other 0 Retardant/Accelerator(name) <br /> POMMAL Installed By ❑Driller ❑Pu np Contractor ❑ Other <br /> ❑Concrete Pedestal❑Dke.nsions:Width ft Length ft Thick <br /> in ❑Christy Box ❑ Stow PIPs 86T 0 3 2022 <br /> FE ❑Submersible❑Turbine ❑ Other HP Pump Set ft Standing Water ouiN couNry ft <br /> Piot Plan Requirements: Attach a plot plat with the exact location of water well with respect to the f0ildwiiWj1 itaMMN GPS <br /> Coordinates, property lines, adjoining properties, water bods or courses, drainage pattern, roads, existing wells, structures, <br /> potential sources of contamination,sewers or private disposal.systema. Include distance from two property lines. For Domestic, <br /> AgrkMltnrq IndastrLl we11,provide location of any water wells or surface water within 200'radius of proposed well. <br /> MVV MUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> DEPARTMENT US O LY Ad/I <br /> Application Accepted Rv_(���lC� <br /> Date o 22- Area �1 99 EmployeeID#— <br /> Grout InspectionBy Data c�- c�Z`l, ❑ SPECIAL Well Permit <br /> Pumpe <br /> Pump Inspection By Date F) WAIVER Received <br /> Sol Baring n By Dom- Constnrcled well Depth ft <br /> CoMMENT3 'ti ' 'wvo "-' <br /> wa�e✓ -r.,�Ttr •�t�l 1�.lkr.�I l.t„«.>a l�Cr.,.>!ctcl GI.,..ty L <br /> PE Sc Received, ChscW Amount Bala PWMW Invoice# Well ID# <br /> Codes Info Cash kied Service Reameallf <br /> 70SIo V ' O' <br /> yIc.0 <br /> �� CO <br /> E19)043-060W1= 5.b G f L Z G�ll � <br /> wen r rues : <br />