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1 WELUPUMP PERMIT SAN JOAQUIN CWltTY ENVIRONMENTAL HEALTH DEPARTMENT IWS EAST HAZELTON AVENUE-STOCKTON CA 95205 -(209)4693420 NON-REFUNDABLE PERWr CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE IssuED JOB ADDRESS 16W72 caz, A � CROSSSTitffT `Y APN !✓ _GCJ�' ARCPL SIZE LAND USE APPL1cmm"# OVAMER NAME /` n c � en M40NE oADDRESS n CITYISTAI E21PffiCV 0.b r 6 b2O CONTRACTORl II E 7 CONTRACTOR ADDRESS C1TYI$TATEIZiP / SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CRYISTATErbP LICENSE Gam! ❑ 0-61 ❑ D-09 O Other NUMBER(& vU22_ EXPIRATION DATE 12 5 DoNEmx WELL SArmww C1 General WnerallColiforrn Bacteria(4391);)9 Dibrorrlochlornpropane(4392) Arsenic(4393) 11fiVCWUSE ticlPrii, t ❑ 4rigationlAgricuiltral o in&,suwi ❑Water Quality Monitoring ❑ sad SamPtangCioraderization ❑Public Water System If dllim"Burt Ower water System Name Calved Name or Phom Nzw*w TYPE OF woRK Wen J$Replacement wen ❑well Amerafionwodtfigtion ❑Other ❑ Mo nih r WeRr) R of wens ❑Son Borixl(s) t`or bO""� ❑Geotechnical a of borings ❑Out-ofService Wen ❑ Out-Of-SeIrvice Well Renewal ❑ Repair ❑New PunT ❑ Pump RepWasment ❑ Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Mettwdr y[Mud _ ❑Air Rotary ❑Auger Cable Tod ❑ Push Point [i Other Proposed Wed-D�h ft Excavation in diameter ❑ Open Bottom ❑ Gravel PacVGravei S¢e in diameter ❑CorKkxr Casing in drameber / CondUctor Casing Depth ft Well Caaln9 Dreur in Rodmess/GaigelASTM Sched ❑ Stee!_)(P_ lastic 11 Stainless Steel ❑ Other Grout seal Depth, It ❑ Neat cement(941b nag75-10 yai►rater) U sand cement P -pat water Bemonke(20%sofds) ❑ Other R F(,F I V F n Grout PlaarnentPumped ❑ Fr.Fail ❑Other ❑ Retardant/Accelerator(name) Pyr InStaded By D Ddier 0 Pump Contractor D Other ❑ Concrete Pedestal❑Dimensions:Width ft Lergth ft Thick lin ❑ Christy Box ❑ Shove Plpe ENVIRONMENTAL urtP ❑ Submers"e❑Turbine ❑ Other HP Pump Sel ft Standing Water Level it Plot Plan Requirements: Attach a plot plat: with the exact location of water well with respect to the following items: GPS COordiltates, property lines, adjoining Properties, water bodies or courses, drainage pattern, roads, existing wells, structures, potential sources of contamination,sewers or private disposal systems.Include distance from two property Dues_For Domestic, Agriculture,Industrial well,provide location of any water wells or surface water within 200'radius of proposed well. MINIMUM 24 HOUR ADVANCE.NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 Z- DEPARTMENT USE ONLY ADPL Acted By LCL- Date l b ya �, Area � �j Employee 0# A6; C 11A Inspection By Date ❑ SPECiAL wall Permit Pump Inspeckorl By Date ❑ WA1veR Received Sad Boring Inspection By Data Condtrucbed Well Depth ft COMMENTS �•R' .F,dC��f(-f Y►t i f P r 1 yP,' o o P Codes h�ifo t� Amin mt� Dais ServicePrm><d IF invoice al wen W# L 3 D Igo y I )S S yfqoq1,113 3 I,) ; "7 h h1 0 Op 14,z EHDM3-46 04MU21M ��/ b ! ]/� 1 'L z wen i rip Pmu: