WP0043451 - Laserfiche WebLink

Home Browse Search

i ` WELLIPUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - t20914683d2n GfVYII I a _Aff K ILU9 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED [CROSS B ADDRESS �� '� p11, / 'h CITYIZIP STREET �'`APN�'!L7pgRCEL SIZE �LgND USEAPPLICATION # NER NAME ) `/� DOWNER ADDRESS CONTRACTOR ICONTRACTOR A SUBCONTRACTOR PHONE CITYISTATE21P�t(/'�'Qi'yj PHONE �1L�L�' �cJ>' CI Y/STATEIZIP r- �s PHONE - 1-4 SUBCONTRACTOR ADDRESS Crry/STATE/ZIP LICENSE ''t' C-57 J C-61 ElD-09 0 Other NUMBER/��.� EXPIRATION DA _ - ---- —""III "��Ctav1-onrorm bacteria (439 1) Dibromochloropropane (4392) Arsenic (4393) INTENDED USEW Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring ❑Soil Sampling /Characterization Public Water System If different from Owner: TYPE OF WORK New Well 1 Replacement Well Water System Name 7 Well Alteration/Modification Other - Monitoring Well(s) # of wells 7 Soil Boring(s) # of borings Out -Of -Service Well Contact Name or Phone Number Geotechnical # ��tjjn�s Retardant / Accelerator Installed By - Driller Pump Contractor Other Concrete Pedestal --Dimensions: Width ft Length ft Thick Christy Box Stove PiDe I rUMP Submersible Ei Turbine ❑ 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 thefollowing 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. NIININIt .1I 21 1101 k ADN ANCL :NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 DEPARTMENT USE ONLY Application Accepted By Date Employee ID# Z Area �` Grout Inspection By Date S ECIAL Well Permit Pump Inspection By /L Date Z7 D WAIVER Received Soil Boring Inspection By Date Constructed Well Depth COMMENTS g Page I ort Well / Pump Permit D Out-Of-Sernce Well Renewal -: New Pum , -Pum Replacement _ Pum Re air :-i Cross -Connection Repair - Raise Well �� 1� WELL CONSTRUCTION Ci asn Drilling Method Proposed Well :_ Mud Rotary ❑ Air Rotary Auger - Cable Tool Push Point Other JU Depth ft Excavation in diameter -i Open Bottom -1 Gravel Pack/Gravel Siz - Conductor Casingin di' r in diameter Well Casing / Conductor Casing Depth Diameter _ in Thickness/Gauge/ASTM Sched r Steel ft Plastic -_ Stainless Steel U/NCO - F6 RONN Grout Seal Depth ft Neat Cement 941b ba 5 10 a/ water 9 ) -: Sand Cement �� NT Bentonite (20% solids) Other sack mix Npr Grout Placement Method P,imn.A - c7— C-11 Retardant / Accelerator Installed By - Driller Pump Contractor Other Concrete Pedestal --Dimensions: Width ft Length ft Thick Christy Box Stove PiDe I rUMP Submersible Ei Turbine ❑ 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 thefollowing 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. NIININIt .1I 21 1101 k ADN ANCL :NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 DEPARTMENT USE ONLY Application Accepted By Date Employee ID# Z Area �` Grout Inspection By Date S ECIAL Well Permit Pump Inspection By /L Date Z7 D WAIVER Received Soil Boring Inspection By Date Constructed Well Depth COMMENTS g Page I ort Well / Pump Permit D