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T� WELUPUMP PERMIT <br /> SAN JOAOUW Coumn ENv%ROWFMAL HEALTH DrPARTMFNT 1868 EAST HAZELTON AVENUE.STOCKTON CA 95205-(209)4d&]420 <br /> WON-REFUNDABLE PERMIT _ - CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOS Aobltes5 J f'1 V l : . GTYIZIP <br /> CRO""EET9 T- ilrl .'C) -I(Q�- t". <br /> . -.....__ _ t. ARC£L SIZE LANO USE <br /> �7 _ Appu,c�-A1nohi R 3 ___ in <br /> JMNRNAMT <br /> HC -_qnE ` D <br /> it?wNERAnwtEss r�- I��O F_. J[.L iqQr)"1 —} Cm/sTATEIZIP jfi>5�T cJ(DJ.Z <br /> lCOKrR4CTDR (� PHONEN.E.�1V/�5q /r {1L <br /> OO� <br /> COMRACUM ADORE55 9 (` <br /> 1 Q_C(c _✓_l..l!1.L 1.O L.1-_L��..- --. mISTATFf71P ��_�(�{10n <br /> .1..1 1 CR 95i,,Q( � <br /> SIMTRAC'Tt,R - <br /> '- <br /> --._ ..._ ..._„_ ... ___.._ -..._....__-__.__._ PHONE <br /> SURCOMMAcrOR AnOR6s ..._ CrrYISTATEIZIP <br /> ILICHlsE yC•57 C-61 i" D-09 Other _ NUMBER_Il1 ExPIRATIONDATE_�� '� 2Q23 <br /> f --- --.�__.. - ------ ------ - <br /> DOMESTIC WELL SAMPLING:)(General M)nerallColiforrn Bacteria(439 1)XDibromochloropropane(4392) Arsenic(4393) <br /> IMTENDEQ USE >rpomeshcMnvate Irrigalion/Agricvlwral Industrial Water Cluality Monitoring Soil SamplingfCharacterization <br /> Public Water System <br /> II fnam 0­01 - Water System Name Contact Name of Plane Nurnber <br /> TWE OF WORK \New Well Replacement Well Well AlterationNAodification ❑Other <br /> Monitoring Wel1(s)_.___ a of wells Soil Boring(s) x 01 b0609s ❑Geotechnical e d borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> )(New Pum. Pump Replacement Pump Repair ❑Raise Well Casing _ <br /> 'WELL CioNs-muc-1oA <br /> Drilling M shod x Mud Rotary Air Rotary Auger C Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth 3Q1 T_ft Excavation in diameter ❑Open Bottom $Gravel PaddGravel Size_in diameter <br /> Conductor Casing in diameter I Conductor Casing Depth It <br /> W=I1 Casing Diameter-IQ In Thlckness/Gauge/ASTM Sched sl�)R z1 ❑Steel YPlastic ❑Stainless Steel Other <br /> Grout Seal Depth ._200 _.. (1 Neat Cement(941b bag/5.10 gal wafer) k mad7 gal water <br /> X XBentonite(20% Other <br /> Grout Placement IitYflfdd)C Pumped Free Fall Other ❑ Retardant)Accelerator(name) <br /> iPEOESTAL Installed By )C Driller Pump Contractor ❑ Other <br /> --- <br /> )c Concrete Pedestal Dimensions:Width�_It Len hIt Thick fol' <br /> i!'• Chritay Box Stove Pipe <br /> PUMP' Submersible Turbine Other HP i2 Pump Set )a It Standing Water Level _ It <br /> Plot )'late Requirements: Attach a plot plan with the exact location of water well with respect to the followings " L <br /> Cuurdinetes. prtoprtty Burs, adjoining propertim, water bodies or courses, drainage pattern, roads,existing weftE4t1+62lBf1Rr3;E" <br /> potential miurf:r,of contamination, .ewers or private dlspucal systems. Include distance from two property lines.For Domestic, <br /> Agriculture.Induostrial Nell.providr locatiou of any water welk or surface water within 200'radius of proposed well. <br /> hu'•INIt M 24 1101 H.111,11%4%( I NOTICE*HI:Ol'IItEU FOR it NS-I'LEASE t'4LL(209)753-7697 <br /> DEPARTMENT�/S lcO O�tJ Area-_/ /� Employee I DtJ <br /> Au�phcatlon Accepted By Date..-.. /-/ <br /> Grout Inspection By Date-. SAN- Zo1-? SPECIAL Well Permit <br /> Purnp Ins{r,ctlun By ;X`'v` D.I. - ?� WAIVER Received <br /> Sod boring Inspectlon By r \ Date _. Constructed Well Depth H <br /> COMMENTS <br /> r--VE--7-SC Ru:.ulvod ChrsekW Amount Permit/ j <br /> t <br /> Oa --' <br /> ! Codes ! Into f3 � cl Rbinittrd / Service Roguest NInvoice WellIDN <br /> _ + <br /> X76: V ?10 y WPo04404_�._ <br /> IS( I WP0044048_ <br /> y391_ 1 I iss WPoo4404-7 _ <br /> x/39 7& 00 APA <br /> LIIINN�Irw fu!n^ f.. �..i � WclllPump[limit <br /> �571 -- <br /> s ll 3 I f JO biz 2 k.6 <br /> 1 <br />