Laserfiche WebLink
1 WELUPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN-KEFUNDAB_LE PERMIT _ _ _ GALL (ZUyZ8b3-/b9! FOR INSPECTIONS _LAPIKt, 7 TEAR FROM DATE ISSUED <br />JOB ADDRESS 93� 0 E. Yl ID& RP A p �— Cm'/ZIP L Ob ) Z 952 M 6 <br />CROSS STREET UEAN RA AP 0ti `O Ola PARCELSIZE 0•110,L LAND USE APPLICATION#_"VNDLLSTR(f{L <br />OWNER NAME VALLEY,_ AA CA F I C FCT kGLE km Ff ei1C.11 6,:11,1112LLC PHONE 760) (U6 - 3 M <br />OWNER ADDRESS _ 130 E. Vi dog Pb CrrY/STATE/ZIP L'Obl /LA <br />CONTRACTOR Kh-0- -61"t (rIJGIPECRING LALVKklpR l INL_. PHONE &Iib 375 - t,7no_ <br />CONTRACTOR ADDRESS f00 �GRL�� ��_ CITY/STATE/ZIP 5A4AAhEwr4>1C.A/g51gJ( <br />SUBCONTRACTOR _1,bi%S I E lLpLa P A-1 l bN PHONE ( J <br />_�7) 1 D5 / J y <br />r+ <br />SUBCONTRACTOR ADDRESS F:-01 3.0K /33 <br />J3 CITY/STATEIZP EsL a L p N l GA j 9s,� 2.0 <br />LICENSE ;<C-57 U C-61 ❑ D-09 LI Other NUMBER 7 r 0-T .6 L EXPIRATION DATE 01/31/2.07-4 <br />DOMESTIC WELL SAMPLING: 0 General Mineral/Coliform Bacteria (4391) 0 Dibromochloropropane (4392) ❑ Arsenic (4393) <br />INTENDED USE U Domestic/Private 0 Irrigation/Agricultural U Industrial ❑ Water Quality Monitoring A Sall Sampling/Characterization <br />0 Public Water System <br />If different from Owner. Water System Name Contact Name or Plane Number <br />TYPE OF WORK ❑ New Well 0 Replacement Well 0 Well Alteration/Modification U Other <br />i I Monitoring Well(s) # of wells U Soil Boring(s) n of borings ;dGeotechnical Z u olbodngs <br />I I Out -Of -Service Well LI Out -Of -Service Well Renewal U Cross -Connection Repair <br />I I New Pump U Pump Replacement u Pump Repair U Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method U Mud Rotary I I Air Rotary X Auger 1:1 Cable Tool U Push Point U Other <br />Proposed Well Depth 10 ft Excavation ll�— in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size _ in diameter <br />IJ Conductor Casing in diameter / Conductor Casing Depth fl <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched — U Steel ❑ Plastic ❑ Stainless Steel U Other---- <br />Grout <br />ther__Grout Seal Depth d d ft 11A Neat Cement (94 /b bag15-10 gal water) U Sand Cement _sock mix17 gal water <br />0 Bentonite (20% solids) 0 Other <br />Grout Placement Method U Pumped X Free Fall U Other 0 Retardant / Accelerator (name) <br />PEDESTAL Installed B 0 Driller H Pum Contractor ❑ Other PAVAN'.. <br />Y P <br />0 Concrete Pedestal UDimenslons: Width It Length ft Thick____ <br />in 0 Christy Box 11 Stove Pipe <br />PUMP t:l Submersible[.! Turbine U Other HP Pump Set ft Standing Water Le <br />Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the followfn items: GP <br />Coordinates, property lines, adjoining properties, water bodies or courses, drainage pattern, roads, existing WC1 SiNfummiv <br />potential sources of contamination, sewers or private disposal systems. Include distance from two property lines. 1fdi''1fYie[;ks1)4T <br />Agriculture, Industrial well, provide location of any water wells or surface water within 200' radius of proposed well. <br />MINIMUN1 24 HOUR .ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209) 953-7697 <br />J / DEPARTMENT USE ONLY <br />Application Accepted By � Z' Date �S <br />Grout Inspection By Date <br />Pump Inspection By Date <br />Soil BoringInaction By Dtto <br />COMMENTS -. I / eYA�t I C �' Ui(� 1 G fDUyG/►rJl1 r IS Pr�L <br />Area C1–I Employee 10# Ft,(, n IL <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />d Well Depth <br />ft <br />PE <br />Codes <br />Sc Received Cheek#J <br />Info flesh <br />Amount Date Permit! <br />Remitted Service Request # <br />Invoice # Well ID# <br />437a <br />8 22 <br />Eiu)fA3.nG w2snon Pagc 1 or Well/ F.W Permit <br />