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1 WELL/PUMP PERMIT <br /> SAN JoAgm CouNTY ENvuiawEmTAL HEALTH DEPARTMENT 1868 EAST HAmToN AvENUE-STOCKTON CA 95205 -(209)488.3420 <br /> NON-REFUNDABLE PERMIT CALL 208 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR.F,�RRO�M�jDATE ISSUED <br /> CROSS STREETMAYA APN EfI ';J1 V''-1( U PARM SRE Q_LAM USE A/PPP"UUCATION# <br /> OWNER NAME ItKPHONE <br /> OWMER AoDREss CITY/STATEfaP SSGI( <br /> CONTRACTOR 11 PHONE f� <br /> CONTIWCTDR Ao== CRY/STATFILP0 �l <br /> 31JEOOKtRACTOR PHONE <br /> SuncoKritAcToR AooRE= CWfMTATEar <br /> LSE *1 F-±! ❑ G-61 ❑ D-09 ❑ Other NUMBER EXPIRATION DATE <br /> DOMESTIC WtFu SAMPLNG:U General Wrorai/Coliform Bacteria(4391) Dibromochiompropane(4392)a Arsenic(4393) <br /> esticPri,rate ❑ Irrigalion/Agriafhxai ❑ Industrial ❑water Quality Monitoring ❑Sal Sarnpi*Characterizatioc <br /> Pubic wafer System <br /> If 40arert 6om Owner: Wafer gpbm Name Cortaa Name or Prone Nmlbw <br /> nn OF Worx well Repacernent Wei ❑Well AlterabonlModification ❑06W <br /> MenitOrlrrg W s) #of weft ❑ SON Borings) 'Tor bong ❑ Geoi echniCal f of bO1+"ee <br /> ❑ Out-Of-Service well ❑ Out-Of-Service Well Renewal ❑C4oss-Cortnection Repair <br /> ❑ New Pump ❑ Purnp Replacement ❑ Purnp Repair ❑ Raise Wel Casing <br /> WELL CONaT0UC110M <br /> Drrlkap tilethod ❑Mud Air Rotary ❑Auger ❑ Cable Tod ❑ Push Point ElOther <br /> Propoeed WM Depth _ft EmawbOn ��n diameter ❑ Open Bottom YGravel Pack/Gravel Size in diame6er <br /> 11 Casingin diameter / CMA^UCt�nr Casing Depth ft <br /> Wed Cm*Q Diameter inTl**nessraugelASTM Scred_ ,k 00— ❑ Steel Plastic ❑ Stainless Steel ❑ Other <br /> — <br /> (km*Sed Depth ft ❑ Neat Cement(94 m beg--10 gal water) Sand Cement sack ff r gal water <br /> *Beraorrite(20X sdlds) ❑Other <br /> Gamut PIt esmat Mdtad Pumped ❑ Free Fag ❑Other ❑ Retardant/Accelerator(name) <br /> ir ®� <br /> p � ntaied By ❑DrNer D Punp Codr-aaor ❑ other NT <br /> n Concvtft PodostW❑Dbrleredww:Width ft Length ft Thick <br /> it ❑Chrlshr eat ❑ Stow Pipe ED <br /> law ❑Submersiae❑Turbine ❑Other HP Pump Set ft Starling Water Level ft <br /> Plot Plata Regdreme>,ts: Aam* a plot plan with the exact location of water well with respect to tate following ite 2022 <br /> Coordinates, property Em's, adjoining properties, water bodes or coarses, drainage pattern, roads, existing wells, <br /> potential sources of coetandnatios,sewers or private disposal systems. Include distance from two property lines- FobN OUNTY <br /> Agrkattnre,Ldssrial well,provide location of any water wells or surface water within 200'radios of proposed well. ;MMIENTAL <br /> HEALTH D EPA RTMENT <br /> MINIMUM 24 SOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date 9 7 as Area`s Emyee ploID# <br /> Grox Inspection gy Dale L ti ❑ SPECIAL Well Permtt <br /> Pump Inspection By Dolle ❑ WAIVER Received <br /> Sol Boring Inspection By <br /> Dale Constructed Well Depth ft <br /> coMMENTs E x i s m yi e l be r eof a , 5 e fa E Q i m I <br /> PF SC Codes Into IW Red T Amount paw #rmw Invoice 0Well 00 <br /> 37 JR0 a c 2.1 <br /> W 3 1$s <br /> 43Rd 7 <br /> L►3�y3 d <br /> ?�p b Z T 6 13 Z Z 1 )3� 1�Z wean/Puav P«,rA <br />