Laserfiche WebLink
r <br />I WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 186E EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />14UIV-KEFUNUABLE PERMIT , GALL Ubly53-/by/ FO INSPECTIONS LAVIK,Lb l YEAR FROM UATE ISSUED <br />.JOB ADDRESS�� S�"� v CITY/ZIP 6v eG <br />CROSS STREET /0-4 b redA,T APN 0 q 0 06 PARCEL SIZE�I�LAND USE APPLICATION # <br />OWNER NAME ��/L%[/ / PHONE <br />� - �/— Z �' 04 <br />OWNER ADDRESS / Z 7� //Ji�� �jr/�'� ��`< CITY/STATE/ZIP <br />CONTRACTOR PHONE <br />CONTRACTOR ADDRESS \ CITY/STATE/ZIP <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE C-57 C-61 I D-09 I Other <br />PHONE <br />CITY/STATE/ZIP <br />NUMBER EXPIRATION DATE <br />DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) ❑ Arsenic (4393) <br />NTENDED USE X Domestic/Private Irrigation/Agricultural - Industrial -i Water Quality Monitoring ri Soil Sampling/Characterization <br />Public Water System Z—� c;— 3�5 -3`o� <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK / New Well Replacement Well Well Alteration/Modification Other <br />i Monitoring Well(s) # of wells I Soil Boring(s) # of borings I I Geotechnical # of borings <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />New Pump Pump Replacement Pump Repair Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method I Mud Rotary Air Rotary I Auger I i Cable Tool CI Push Point I Other <br />Proposed Well Depth ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft �ANi p <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched Steel -i Plastic Stainless Steel -i Other ,�! j <br />Grout Seal Depth ft F- Neat Cement (94 lb bag/5-10 gal water) -i Sand Cement sack m/ <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped - Free Fall - Other Retardant / Accelerator (name) -Mi4 Z2.1 <br />PEDESTAL Installed By CI Driller ni Pump Contractor Other OVIJ n c { - , <br />Concrete Pedestal '_IDimensions: Widthfr ft Length _ ft Thick FS <br />�in Christy Box Stove Pipe RARi;;c!: <br />PUMP X'Submersibler Turbine -1 Other HP Pump Set� ft Standing Water Level ft <br />Plot Plan Reuirements: 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 />MININIUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />DEPARTMENT USE ONLY <br />Application Accepted By T, l��� Date 3 ly " <br />Grout Inspection By Date <br />Pump Inspection By Date (oAQ�Z-�ZZ <br />Soil Boring Inspection By Date <br />COMMENTS tdPW 14011 WPOOU34a, IAlel1 Derm)4 la <br />Area 4 Cf Employee ID# <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth ft <br />3s 1A) 0;1 Aviv aylasc <br />i"z,fl runt - t% ._.4,,-0.n <br />PE Sc Received Check#/ Amount Date Permit/ Invoice # Well ID# <br />Codes Info ---CastL Remitted Servic Request # <br />3 0 o, ! I S,;I I ZZ <br />EHD043-06 10/25/2021�W-")� 0/ �jag� Well /Pump Permit <br />T <br />-i <br />M <br />D <br />0 <br />0 <br />m <br />m <br />N <br />)19, <br />