Laserfiche WebLink
WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AvENUE - STOCKTON CA 95205 - (209) 4683420 <br />NON-REFUNDABLEPERMIT �/ CALL 12091953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />iIJos ADDRESS Iy�y� � L K I 0- i n IR 4 tyto UCrTMfLP <br />Q <br />CROSS STREET!DO\iN\9—J1S J TT U APN'Zf`i%— — b _PARCEL SIZE -)6-q _LAND USE APPLICATION # <br />I, FRH Realty LLC PHONE 858.414.6341 _ <br />OWNER NAME San Diego, CA 92121 <br />OWNER ADDRESS 5355 MiraSorrentoPlace, Suite 100 Cm�ISTATEfZIP _ _-- --_ '{� <br />'CONTRACTOR %' '1M,C(,,/J \� arOl'} {�,_, I ,PHONE (%?) �Z -�—`�8 <br />CONTRACTOR ADDRESS 1 2-+S 6101 fie. YOJ P1 CrTYISTATEIZIP LOt41,":D a Cg,,15330 <br />. SUBCONTRACTOR \ - eS-t- Q-cic&s F- E�(� 1 v r +�' 1 PHONEl jp�q� gv�0J1 - � I <br />SUBCONTRACTOR ADDRESS PC) eox * 1;j CCITYISTATE01i E5c-atov1, Co, "15320 <br />LICENSE A C-57 C-61 . D-09 Other NUMBER 0�D +G I EXPIRATION DATE 1/31/24 <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (439 1) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE Domesbc/Pnvate C ImgationlAgncullural - Industrial IWater Quality Monitoring Soil SamplinglCharaclenzation <br />Public Water System <br />If ddfereni from Owner Water System Namo Contact Name or Phone Number <br />TYPE OF WORK New Well Replacement Well Well Alterat.oniModificalion Other <br />Monitoring Wells) # of wells )( Sod Bonng(s) !- ° or bongs Geotechnical $Ibf borngs <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />New Pump Pump Replacement Pump Repair Raise Well Casing <br />I <br />!WELL CONSTRUCTION <br />Drilling Method Mud Rotary Air Rotary XAuger Cable Tool Push Point Other <br />Proposed Well Depth _ft Excavation _�_ in diameter Open Bottom - Gravel Pack/Gravel Size in diamet <br />%ter) <br />Conductor Casing in d ame:er I Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/GaugeIASTM Sched Steel Plastic Stainless Steel Other <br />Grout Seal Depth .Q It -� Neat Cement (94 Ib bagl5-10 gal water) Sand Cement sack mlx17 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped )I Free Fall Other . Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor Other - <br />Concrete Pedestal Dimensions: Width fl Length <br />Ch ' Box Stove Pipe <br />Thick <br />n nsty <br />PUMP Submersible Turbine Other HP Pump Set It Standing Water Level' I(,C <br />yl <br />f'la( flan Requirements: Attach a plot plan with the exact location of water well with respect to the followin r items: , <br />Coordinates, property lines, adjoining properties, water bodies or courses, drainage pattern, roads, existing s <br />potential sources of contamination, sewers or private disposal systems- Include distance from two property line <br />Agriculture, industrial well, provide location of any water wells or surface water within 200' radius of proposed v <br />RI 01 IRI 11 1 OR IV PIA I IONS - PI I k�l l %I I i.na, <br />DEPARTMENT USE ONLY u/� <br />Application Accepted By Dale was�aa Area 43 r Employee ID# A5 <br />Grout Inspection By Data SPECIAL Well Permit <br />Pump Inspection By <br />Sod BoringInspection By <br />COMMENTS /I B1 2i C_ <br />PE Sc <br />Godes Info <br />q37r2 _Ls <br />Date WAIVER Received <br />Date Constructed Well .Depth ft <br />T <br />D <br />0 <br />0 <br />a <br />M <br />a <br />Received <br />By <br />heck#I <br />Amount <br />Remitted <br />Date Permit/ <br />Service Request # _ <br />Invoice # <br />Well ID# <br />w.0 P—P ria <br />I !r <br />