Laserfiche WebLink
1 WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN-KEFUNDABLE �VERMIT I / LeALL (LUU).U04-1OUI FUR INSPECTION5 tAr'IMMO -1 TEAK FKUM LJAI.E I55UEU <br />JOB ADDRESS 13 1/ 71 /w¢`SL I /�oy`A{�erriC �V4 CITY/ZIP S'/ 0/1 QJZO-; <br />T <br />CROSS STREET <br />rz—Sl�lng A."', � AP I-0K-�zl50 - /OU PARCEL SIZE LAND USE APPLICATION # <br />OWNER NAME [ �o.4v�wn,/�s / 'E'J n en t Is -4 PHONE � <br />OWNER ADDRESS J3`y 'fin/ /GvbJnh oo� /Dr A CITY/STATE/ZIP-Z-4t, LI 52_V7 <br />CONTRACTOR <br />CONTRACTOR ADDRESS, <br />PHONE <br />CITY/STATE/ZIP Go& '_-4 951 12 <br />SUBCONTRACTOR <br />/PHONE('L <br />SUBCONTRACTOR ADDRESS 3o5o Lt3"Tt!`P 3rf2—�ti3'-� <br />cCIITY/STATE/ZIP W� /�p�— <br />/� <br />LICENSE P C-57 ❑ C-61 C1 D-09 11 Other NUMBER / �tO EXPIRATIONDATE 'f/3d2 <br />DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) ❑ Arsenic (4393) <br />INTENDED USE ❑ Domestic/Private 0 Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring VSoil Sampling/Characterization <br />❑ Public Water System <br />If different from Owner. Water System Name Contact Name or Phone Number <br />TYPE OF WORK ❑ New Well ❑ Replacement Well <br />❑ Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings Geotechnical f # of borings <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />LEI <br />Li Kalse vveii <br />WELL CONSTRUCTION // <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary 19'Auger ❑ Cable Tool ❑ Push Point ❑ <br />Proposed Well Depth 20 ft Excavation 9 " in diameter ❑ Open Bottom <br />❑ Conductor Casing in diameter / Conductor Casing Depth <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Pla <br />Grout Seal Depth C7 ft VNeat Cement (94 /b bag/5-10 gal water) ❑ Sal <br />D Bentonite (20% solids) D Other <br />Other REc�NT <br />E <br />❑ Gravel Pack/Gravel Size in i r <br />ft �2 2021 <br />>tic ❑Stainless Steel Other <br />d Cement �AN JQfttmlKl7.,w.I water <br />Grout Placement Method ❑ Pumped 9 Free Fall 9Other 11-a.,'a� : ❑ Retardant / Accelerator (name) . "ter `IRTMc <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal ❑Dimensions: Width ft Length ft Thick <br />in ❑ Christy Box ❑ Stove Pipe <br />PUMP ❑ Submersible❑ Turbine ❑ Other HP Pump Set ft Standing Water Level ft <br />Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the following items: GPS <br />Coordinates, property lines, adjoining properties, water bodies or courses, drainage pattern, roads, existing wells, structures, <br />potential sources of contamination, sewers or private disposal systems. Include distance from two property lines. For Domestic, <br />Agriculture, Industrial well, provide location of any water wells or surface water within 200' radius of proposed well. <br />MINIMUNI 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />DEPARTMENT USE ONLY <br />Application Accepted By Z' 1, Date IlPhaja <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By �.(✓�%� <br />COMMENTS <br />Date <br />Date <br />Date 2 <br />Area yr �1 "� k f�h Employee ID# /o r ` <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth <br />ft <br />T <br />-{ <br />m <br />D <br />v <br />v <br />m <br />to <br />m <br />PE <br />Codes <br />SC Received he <br />Info BV Cash <br />Amount Date Permit/ Invoice # Well ID# <br />Remitted Service Fgqwst # <br />q37al <br />150 <br />% <br />EHDO43-06 1025/2021 Page I of 2 Well / Pump Permit <br />