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EMAILED <br /> 1 WELL/PUMP PERMIT <br /> SAN JDAom Cam"ENVWONI ENTAL HEALTH DEPARTMENT 7868 EAST HAM-row AVENUE-STOCKTON CA 95205 -(209)468-3420 <br /> NON-REFumDABLE PERW CALL 209 953-7697 FOR IHSPECTIOW EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joe ADDRESSW Crr IZIP <br /> CROSS MEET r APN—tR - PARCEL SM VIAND USE APPLICATION# <br /> OWNER NAME C_I1 PHONE 5� <br /> OWNER ADDRESS -r-- /STATE/Zr <br /> CONTRACTOR <br /> CONTRACTOR ADDRESS 1 CrTY1sTATElZP <br /> PHONE <br /> SUBCONTRACTOR <br /> SUBCONTRACTOR ADDRESS CnY/STATE/2r <br /> LK"ISE G67 [1C-61 El D-09 ❑ Other Numwit ExwrtATroN DATE <br /> DomEsTic 111ELL I fAr raUCoWorm Bacteria(4391) ibromochbroprbpane(4392)❑ Arsenic(4393) <br /> I Uzapomesfidprivate D ImgationlABriaMurel ❑ Industrial Water Quality Monitoring ❑ SOR SemplinWCharactertzation <br /> ❑ Public Water System <br /> M arbrew Unm Orrww Wabr n Name Cased Name or Phone Number <br /> TYPE OF WNew Well ❑ Replacement Well ❑ Well ARendioni Modification ❑ Other <br /> [I Monitoring WeN(s) #of wells ❑ Sol Bonng(s) #of��' ❑ Geotectwkal *of bairpe <br /> ❑Ou14X-Service Well ❑ Cot-OfService Well Renewal ❑Cross-CaMectlon Repair <br /> D New Pump D Pump Replacement ❑ Pump Repair ❑Raise Wall <br /> Cuft <br /> DrI"Method Mud ❑Air Rotary ❑Auger ❑Cable Tod ❑ Push Point D Other <br /> Proposed Well! Depth <br /> R h it Excavation /�-in diameter ❑ Open Bottom *Gravel Pack/Gravel Size in diameter <br /> ❑ Casing in diameter I Conductor Casing Depth ft <br /> Well Casino Diameter in TnidnesdGaugelASTM Schad ❑ Steel ❑ Plastic D Stalrress steel ❑ Other <br /> Grout Seal I it D Neat C nerd(94 ib beg(5-10 gal waW ❑ Sand Cement sack mbd7 gal water <br /> 20%solids) ❑Other <br /> Grout Piscerrlerrt ettlod Pumped ❑ Free Fail ❑ Other ❑ Retardant/Accelerator(name) <br /> 4 Installed By ❑ Driller ❑ Pump Contractor ❑ Other PAVMENTS <br /> ❑ Concrete Pedestal DDinen kns:Width ft Length It Thick RECO=nil <br /> rin ❑ Cheaty Bou D atova Pipe <br /> tPW ❑Submersiibien Turbine D Other HP Pump Set It StanclirdhaPa ft <br /> Piot Plan Requirements: Attack a plot ptai with the exact location of water well with respect to tlhea q%*p$odRTp-s: GPS <br /> Coordinates, property lines, adjolaiNg propertks,water bodies or courses, dralaage patters, reaftex1kCE <br /> tamt�Ctures, <br /> potential sources of coaination,Sewers or private disposal systems. Inclade dbfesta two festwo property lues- or mestic, <br /> Agriculture,Industrial well,provide tocation of any water wells or Surface water within 200'radius of proposed well <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECI"IONS-PLEASE CALL(209)953-7697 <br /> DE ARTMENT USYOY <br /> Application Accepted By Date Z13 2*;' Area Employee ID# <br /> Grout Inspection By — Dace 0 SPECIAL Well Permit <br /> Pump In:spediat By Date 0 WAIVER ReColved <br /> Soil Boring Inspection By Date Consbucied well Depth) R <br /> COMMENTS <br /> PE SC Amount Per Ifu Invoice R Well IDR <br /> Cod"Codinfo CCW* RMnitbd Service R art <br /> r D (o& <br /> EHDOOft PW l ore win rm.4 ae,n. <br /> 007f= li / kvzL <br />