Laserfiche WebLink
WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT <br />Amount <br />CALL 209 953/-7697 FOR INSPECTIONS <br />CALL <br />EXPIRES 1 YEAR FROMDATE ISSUED <br />JOB ADDRESS 7C <br />' " ^ �� CITY/ZIP <br />r /132 <br />CROSS STREET �anccy <br />` �} <br />APN O 6-3-z6 © l7 PARCEL SIZE 5 <br />,{p <br />y- LAND USE APPLICATION # <br />r <br />OWNER NAME <br />r/iC, i3OVe( 1- S <br />PHONE-"©� <br />7JJdv0 <br />D� <br />OWNER ADDRESS!, <br />—J <br />C <br />% <br />//qe!7 <br />CONTRACTOR YQhiZ <br />PHONE <br />�7 <br />Op5 <br />CONTRACTOR ADDRESS <br />CITY/STATE/ZIP <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE ❑ C-57 A1C -61 Cl D-09 ❑ Other <br />PHONE <br />CITY/STATE/ZIP Q <br />NUMBER I O ?to EXPIRATION DATE <br />DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) ❑ Arsenic (4393) <br />INTENDED USE `eDomestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil 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 ❑ Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings ❑ Geotechnical # of borings <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal Q Cross -Connection Repair <br />L rum <br />Drilling Method Mud Rotary ❑ Air Rotary ❑ Auger n Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br />I Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Schad ❑ Steel ❑ Plastic ❑ Stainless Steel Other <br />Grout Seal Depth ft ❑ Neat Cement (94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br />-1 Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller )f Pump Contractor ❑ Other <br />Concrete Pedestal _!Dimensions: Width __Vft Lengthft Thick tr <br />in Christy Box - Stove Pipe <br />PUMP Submersible❑ Turbine L! Other HP Pump Set Z / ft Standing Water Level /to 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 />MINI MUNI 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />DEPARTMENT <br />USE ONLY �] <br />��;'b .�x F <br />Application Accepted By Date.Area -i �I �i Employee ID# ' <br />Grout Inspection By Date ❑ SPECIAL Well Permit <br />Pump Inspection By '�ti Date 2 C ❑ WAIVER Received <br />COMMENTS <br />k (; <br />EHD043-06 10/25/2021/� h` ,� n , ' , 1 <br />n n � r�� ��1�' I nf? Well / Pr�ermil <br />Amount <br />r <br />03 A <br />EHD043-06 10/25/2021/� h` ,� n , ' , 1 <br />n n � r�� ��1�' I nf? Well / Pr�ermil <br />