WP0043282 - Laserfiche WebLink

Home Browse Search

Y ' WELL/PUMP PERMIT - V IT Sl SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 NON-REFUNDABLEPERMITCALL 209 953-7697 FOR INSPECTIONS L--'A,.EXPIRES 1/YEAR FROM DATE ISSUED JOB ADDRESS `J SSU F_A ST P'a'nLe 12- CITY/ZIP --'A i m o49-I�-�'� D4�-iZv-61 Il},1 roes A 3µ acres o CROSS STREET 1�I" ko-n prII Sopr�Lh APN I t PARCEL SIZE LAND USE APPLICATION t#_ L} o OWNER NAME I�r✓�I I tis ✓G'' �� LL PHONE OWNER ADDRESS ��/ `I �� I L�'�.�C !� .� �v� 3,5� CITY/STATE/ZIP CONTRACTOR l�f�� A5 JA &,,,+At' , 'LC_, PHONE '2 Vq-';6J-37d t CONTRACTOR ADDRESS >)L + N�I��f"" CITY/STATE/ZIP L-ed'. / (A C` LAI SUBCONTRACTOR �t21 t, GIT ��`QrS furl P,✓,ci Ap ssoc,'a+-e 5 L'lc-' PHONE � C�' �/�[�`— SUBCONTRACTOR ADDRESS J O`t ( S Q�L �✓ h� CITY)SgTATE/ZIP 0 G4(,s-/��> / U v, & if z LICENSE VC C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER v 1 0 0 EXPIRATION DATE s l 1 l �2 J DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392)i Arsenic(4393) INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring )W Soil Sampling/Characterization ❑ Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK L New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings )(Geotechnical b #of borings C Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair ❑ New Pump C Pump Replacement ❑ Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION �lvp^ Drilling Method L Mud Rotary C Air Rotary Auger ❑ Cable Tool ❑ Push Point L Other Al A 1. L Proposed Well Depth 1J'30 ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Siz Iameter L Conductor Casing in diameter / Conductor Casing Depth ft SANJOA Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel L Plastic ❑ Stainless St F�l/ N Grout Seal Depth l S ^- ft �I Neat Cement(941b bagl5-10 gal water) E Sand Cement SPH cAh1p I water L Bentonite(20%solids) L Other TMENr Grout Placement Method E Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other ❑ Concrete Pedestal ❑Dimensions:Width ft Length ft Thick in L Christy Box ❑ Stove Pipe PUMP ❑ Submersible❑ Turbine U Other HP Pump Set ft Standing Water Level ft Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the following items: GPS Coordinates, property lines, adjoining properties, water bodies or courses, drainage pattern, roads, existing wells, structures, potential sources of contamination, sewers or private disposal systems. Include distance from two property lines. For Domestic, Agriculture,Industrial well,provide location of any water wells or surface water within 200' radius of proposed well. N11NINIt N1 23 HOUR ADVANCE N(YI R L RLQIIRED FOR INSPECTIONS-PLEASE('ALL(209)953-7697 DEPARTMENT USE ONLY /� lq Application Accepted By —ice Date S �1 c7oZ Area i -/ Employee ID# Grout Inspection By Date .� Z� L PECIAL Well Permit Pump Inspection By Date L WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ftft COMMENTS TIC. jo bc- j,).st-CJ i PP, Cr ,?ej O 1,,} o r , F' T o o n r P/ is epcjunTereCl 1' f PE SC Received hec Amount Date Permit/ Invoice# Well ID# Codes Info as Remitted Seryi a Request# L 37,9 ISO EHDO43-06 04/07/2022 Page I o1 2 Well/Pump Permit