Laserfiche WebLink
I WELUPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT <br />JOB ADDRESS <br />CROSS STREET <br />OWNER NAME II <br />OWNER ADDRESS u1 V <br />CONTRACTOR <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR <br />GALL ZU9 953-fbUI FOR INSPECTIONS CA1'IrGCJ T T LAK I-KUM LAIC MZoueu <br />Q ' ' CITYIZIP W <br />_ AP r ,'j — 14 O _Woo PARCEL SIZE '2_0_LANO USE APPLICATION # <br />1-7 <br />P�HONE <br />CtTYISTATE/ZiP <br />PHONE�j"�j% <br />CITYISTATEiLP . Cf1 " � / <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />LICENSE �'C-57 ❑ C-61 ❑ D-09 ❑ Other. <br />NUMBER <br />CITYISTATEIZIP <br />EXPIRATION DATE <br />DOMESTIC WELL SAMPLING: I' General MineraliColiform Bacteria (4391) [ Dibromochloropropane (4392) i i Arsenic (4393) <br />INTENDED USE ❑ Domestic/Private Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sam piing/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 -Orf -Service Well Renewal ❑ Cross -Connection Repair <br />❑ New PumD ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br />Drilling Method MudRota ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point [I Other <br />Proposed Well pth�ft Excavation in diameter ❑ Open Bottom Gravel Pack/Gravel Siz in diameter <br />❑ Conduct Casing in diameter / Condu�ct,o�j�?sing Depth ft <br />Well Casing Diameter V in Thickness/Gauge/ASTM Sched W ❑ Steel Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth lm_ ft ❑ Neat Cement (94 Ib baq/5-10 gal water) Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) ❑ Other <br />Grout Placement Method 'k Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal ❑Dimensions: Width It 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 />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring <br />COMMENTS_ <br />DEPARTMENT USE ONLY <br />Date <br />Dateq'_1 - 2 L <br />Date <br />Date <br />Area 5 C Employees <br />❑ SPECIAL Well PerIT• cI� <br />❑ WAIVER Receivedle/l/ <br />Constructed Well Depth <br />m <br />D <br />0 <br />A <br />y <br />EHD043-0610852021 " n�.}-. Iq 18gq Iof2 Wet] IPump Permit <br />