Laserfiche WebLink
10 <br />I WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1888 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />rvvN-KEruNUABLE rERMIT GALL Aub 11133-f1bVf FOR INSPECTIONS hAVIKLU l YEAR FROM DATE ISSUED <br />JoeADOREss 15656 E. Mariposa Road CR,rnIp ccEscalon, CA 95215 <br />CROSS STREET Mariposa Road APN 183-090-010 PARCEL SrzE :)lJC. LAND USE APPLICATION# <br />OWNER NAME Lagorio Properties PHONE (209) 982-0734 <br />OWNERADORESS 777 N. Pershing Avenue CFnr/STATE/ZIP Stockton, CA 95215 <br />BSK Associates <br />ADDRESS 550 W Locust Avenue <br />FOR BSK Associates <br />FOR ADORESS 550 W Locust Avenue <br />PHONE (209) 769-4734 <br />CITY/STATE/ZIP Fresno, CA, 93650 <br />PHONE (209) 769-4734 <br />Cmr/STATE/ZIP Fresno, CA, 93650 <br />X C-57 . C-61 D-09 . Other NUMBER 490942 E%PIRATION DATE 12131/2022 <br />DOMESTIC WELL SAMPLING: ❑ General MinerallCoiiform Bacteria (4391) ❑ Dibrornochloropropane (4392) ❑ Arsenic (4393) <br />INTENDED USE Domestic/Private -, Irrigation/Agricultural Andustrial Water Quality Monitoring i Soil Sampling/Characterization <br />Public Water System <br />IF diRerenl from OwnerWater System Name Contact Name or Phone Number <br />TYPE OF WORK New Weli Replacement Well Well AlterationtModification <br />Monitoring Well(s) # of wells . Sod Boring(s) <br />Out -Of -Service Well Out -01 -Service Well Renewa <br />Other <br />s or borings X Geotechnical 3X10' a of borings <br />I Cross -Connection Repair <br />Raise Well Casino <br />Illing Method Mud Rotary _ Air Rotary _ Auger Cable Tool Push Point X Other hand auger borings <br />oposed Well Depth 10 ft Excavation 4" in diameter . Open Bottom Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft Pq <br />Well Casing Diameter _ in Thickness/GaugeIASTM Sched Steel Plastic ; Stainless Steel Other <br />Grout Seal Depth ft X Neat Cement (94 lb bagl5-10 gal water) Sand Cement sack r;0 d <br />C1Bentonite (20% solids) D Other <br />,out Placement Method i , Pumped X Free Fall Other Retardant / Accelerator (name) Q n <br />PEDESTAL Installed By Driller ; Pump Contractor Other HNn I cl/ <br />D Concrete Pedestal - Dimon slons: Width it Length ft Thick <br />in G Christy Box Stove Pipe CTu NM �l i <br />1 P C, Submersible, Turbine J Other HP Pump Set ft Standing Water Level "1 //1111 <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 />M I N I NI UNI 24 HOUR %1)% ANCE NOTICE REQUIRED FOR iNSPF,CTIONS - PI FASF. C ai 1 (209) 951-1591 <br />?� DEPARTMENT USE ONLY <br />Application Accepted By �r i"— Z- Z— Date a <br />Grout Inspection By Date <br />Pump Inspection Bym� Date I <br />Sail Boring Inspection By l �L4d158'� �\� Date I (O <br />COMMENTS <br />Area % Employee ID# ` �7 <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth <br />ft <br />i <br />m <br />D <br />O <br />O <br />�T <br />O <br />Y <br />PE Sc Received Check#/ <br />Codes Info B Cas <br />Amount <br />amltted Date <br />Permit! <br />Service Request # Invoice # Well IDN <br />> > <br />?(,0 31.22 <br />WeCIO 0 93 <br />ElID443.0610 25 1021 <br />�38s7o/sg <br />N'cll Punp Panus <br />