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1 WELUPUMP PERMIT SAN JOAwm COUNTY ENVRONMENTAL HEALTH DEPARTMENT 186E EAST HAZELTON AVENUE-STOCKTON CIA 95205 -(209)468-3420 NON-REFUNDABLE PERMIT f CALL 209 953-7697 FOR INSPECTIONS EXWRES 1 YEAR FROM DATE ISSUED JOB ADDRESSyy R j, CITYILP CROSS STREET L/ H roA �'� _ APN ZAV'046 -356 PARCEL SIZE I.ddd LAND USE APPUCATION# A OWNER NAME Kan!w ^Aa4..i k ivl R-d P'r'e ker /gs PHON(j 3 5 Z-bli QiD owNEnADDRrEsa 16693 '�lonll (�J• C"1STArEZIP L1P°�`-r C4 tS3�.L CONTRACTOR Mils-C V t S D r T l h t ctrl!• PHONE S 22- 1-1 20 CONTRACTOR ADDRESS I Crn1STATErZP M o1'C ' ,, Ir .1 S 3 57 SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CTTYISTATEMP LICENSE �KC-57 D C-61 ❑ D-09 ❑ Other NtN11111ER EXPIRATION DATE 1 DOMESTIC WELL SAMPLM:y-General MineraUC 0offn Bacteria(4391), DibmmochlonDprtopane(4392)C Arsenic(4393) INTENDED USE )(Domes6dPrivate D IrrigatiorVAgriculturai D Industrial ❑Water Quality Monitoring ❑ Soil Sampling/Characterization 0 Public water System If dMarect hum Owner Weser System Narne Curled Name or Phone Number TYPE OF WORrc New Well )(Replacement Well O Well Alteration/Modification ❑ Other ❑ Monitoring Wells) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical r of borings ❑ Out-0fService Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair ❑ New Pump ❑ Pump Repleoernent ❑ Pump Repair ❑ Raise Well Casing WELL C INSTRUCTION Drilling Method'd Mud Rotary, 0 Air Rotary ❑ Auger ❑ Cable Tool 0 Push Point ❑ Other Proposed Well Depth ft Excavation in diameter 0 Open Bottom ❑ Gravel Pack/Gravel Size in diameter 0 Conductor Casing in diameter / Conductor Casing Depth ft PAY Well Casing Diameter(0 in Thickness/Gauge/ASTM Schad�a0 D Steel 'Plastic ❑ Stainless SteRE( 1�7 Grout Seal Depth 1010 ft 0 Neat Cement(94 Ib beV5-10 gal wate4 0 Sand Cement sa t mix17 gal water ^entonite(20%solids) O Other Q )n,)`r Grout Piacernent Method Pumped 0 Free Fall O Other 0 Retardant l Accelerator(name) 6AN JOA ENVIRONMEN7AI- �ETAL Installed By 0 Driller PumpC,on#acW D Other ftThldc u��7atBsn,n7r�eiar--- 0 CorrcrsM Pedesht O :Wktth ft Length in 0 Christy Box 0 Stove Pipe Euii— SubmersihleD Turbine 0 Other HP Pump Set ft Standing Water Level ft Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the following items: GPS Coordinates, property lines, adjoining properties, water bodies or coarses, drainage pattern, roads, existing wells, structures, potential sources of contamination,sewers or private disposal systems• Include distance from two property fines.For Domestic, Agriculture,Industrial well,provide location of any water wells or surface water within 200' radius of proposed well. NIINI\11 \1 ?a JPL K %0\ „'tt t };It ittF.11 t(int ial')) DEPARTMENT USE ONLY Application Accepted BY — Z— Date .Z Area Cr�� Employee ID# Grout InspedlDn By " N 2 A L z ❑ SPECIAL Well PetTnit Pump lnapection By Date 1�{ ❑ WAIVER Received Soli Botin9 Inspecdon By Date Constructed Well Depth ft COMMENTS � c- }! t Jr'1 f;c s ¢J%?P d '7; , t✓1 t ,(' 11 (ilF�rr�/fi PE SC Received CheckiN Amount Dam PWMW invoice/ We#ID# as Codinfo B Cash Remitted Service PAquest# 4 310 ?c �r 2 y J Witt, EHDO43-06 t r :