Laserfiche WebLink
I WELL/PUMP PERMIT <br />SAN JOAOW4 COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAzELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT L GALL (ZU9) 953-i'b�J/ FOR INSPECTIONS ) t_ArlKC, l TEAR FROM DATE IssuEu <br />JOB ADDRESS 1-116((0 N . T n o+r A r Ill l� CITYIZIP Lea! / <br />C IT 0)"A5 - <br />CROSS <br />STREET S% 1 ' j APN O 2 S- Z 0 0- 0 JJ 0 PARCEL SIZE 2 f 2 SQLAND UsE APPLICATION # <br />OWNER NAME <br />PHONE 4402 . 6 N q 4) <br />ADDRESS ,P •• V • T4-0 -0-1 Q0- 1 CITYISTATE/Z!P S+a c-k�eh Cw 95 267 <br />ACTOR 1_\flS`G11iS DL'C*%11 V%1 Snc Z - <br />PHONE S2- I,? Z$ <br />kcTOR ADDRESS -1 ( Ot A 1h4 r s Md. Cr"ISTATE/LP '� �Pr-37 <br />CTOR ADDRESS CtTYISTATE/ZIP <br />IOC -57 ❑ C-61 ❑ D-09 ❑ Other NUMBER <br />PHONE <br />ExPIRATION DATE If -30 -2-1 <br />DOMESTIC WELL SAMPLING: G General MinerallColiform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE f1 Domestic/Private Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br />❑ Public Water System <br />H different from Owner- Water System Name Contact Name or Phone Number <br />TYPE OF WORK N(New Well ❑ Replacement Well ❑ Well Afteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of bonngs ❑ Geotechnical <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />Ll New <br />weu <br /># of borings <br />Drilling Method'Q Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth 400 it Excavation '1-1411 in diameter (I Open Bottom )11 Gravel Pack/Gravel Size in diameter <br />i Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter L.6 in Thickness/Gauge/ASTM Sched A.7 -S CO )(Steel E, Plastic [I Stainless Steel ❑ Other <br />Grout Seal Depth_ bA ❑ Neat Cement (94 /b bag, -,10 gal wafer) A Sand Cement / 0..3 sack mix/7 gal water <br />i � Bentonite (20% solids) ❑ Other <br />Grout Placement Method Pumped C Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal ❑Dimensions: Width ft Length It Thick <br />in ❑ Christy Boz ❑ Stove Pipe <br />PUMP ❑ Submersible[] Turbine ❑ Other HP Pump Set ft Standing Water Level it <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 />(INIilU.19 24 IIOUR:1.D%i"CE NO I ICE REQL!lREll 1, OR I\SPEC f IONS - PLEASE C,SLL 1269) 953-7697 <br />DEPARTMENT USE ONLY <br />fI r� �' <br />Application Accepted By �� Date ) /O R % Area I' Employee ID# <br />Grout Inspection By t,,, 'g;,j` k2 ✓f.`� I:kt Date IIT �2L ❑ SPECIAL Well PENT <br />Pump Inspection By Date ❑ WAtvER ReceiviRECEIVED <br />COMMENTS <br />T <br />a <br />0 <br />0 <br />a <br />m <br />is <br />�0e • r� <br />, <br />EHD043416 I W25/2021 Page I oft Well I Pump PEI I <br />