Laserfiche WebLink
WELUPUMP PERMIT <br />SAN JOAQLAN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN -REFUNDABLE PERMIT <br />JOB ADDRESS, <br />CROSS STREET Fivie <br />OWNER NAME <br />GALL (209) 953-7697 FOR INSPECTIONS EXPIRE5 1 YEAR FROM DATE ISSUED <br />A.' N -.4-W CITY/ZIP L 1 f1Ll. 1.0 - I , 'C �J X/ <br />j APN �� 13 L1 oa s PARCEL SIZE-? ' 6 LAND USE APPLICATION # sl <br />1a PHONEalC.I/_ 1) 9—I (�— ICI / Z <br />OWNERADDRESS Vy ! nC�dI �1%� Y, CITY/STATE/ZIP S �'� �7 Jr I S C)q <br />CONTRACTOR O "�l�(�t�"�A 1001 1 I- <br />I S PHONE <br />CONTRACTOR ADDRESS P qV `t) K I 4( { (4(- CITY/STATE/ZI <br />I/, <br />P <br />SUBCONTRACTOR <br />,l v-, PHONE <br />SUBCONTRACTOR ADDRESS <br />LICENSE N C-57 ❑ C-61 ❑ D-09 l Other. <br />NUMBER <br />) q D <br />EXPIRATION DATE <br />DOMESTIC WELL SAMPLING:( General Mineral/Coliform Bacteria (4391),( Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE XDomestictPrivate ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK , New Well Replacement Well ❑ Well Alteration/Modification Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings , Geotechnical # o <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair DPr+ 1) <br />❑ New Pump ❑ Pump Replacement I] Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION E JOROUIN U <br />Drilling Method , Mud Rotary i Air Rotary ❑ Auger ❑ Cable Tool i7 Push Point ❑ Other H r4 F <br />W/ A CO N <br />Proposed Well Depthzim ft Excavation I QL in diameter ❑ Open Bottom X Gravel Pack/Gravel Size Peter <br />❑ Conduc or Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM SchedS� 11 Steel Plastic ❑ Stainless Steel U Other <br />Grout Seal Depth ft ❑ Neat Cement (94 /b bag15-10 gal water) Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) I I Other <br />Grout Placement Method Afumped E Free Fall ❑ Other D Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal i ;,Dimensions: Width ft Length ft Thick <br />n El Christy Box Stove Pipe <br />PUMP ❑ Submersible[] Turbine ❑ Other HP Pump Set ft Standing Water Level ft <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 />MINIMUM 24 HOUR ADVANCE: NOTICE REQUIRED FOR INsI'F.,urioNS - PLEASE CALL (209) 953-7697 <br />DEPARTMENT USE ONLY <br />Application Accepted By Date is 3or� 1 Area Employee ID# F G. <br />Grout Inspection By Date ❑ SPECIAL Well Permit <br />Pump Inspection By DateZZ CI WAIVER Received <br />Soil Boring Inspection By — <br />COMMENTS Le, -e-6 lines <br />SKO <br />Date <br />Constructed Well Depth <br />ft <br />T <br />PE SC ReceivedChec <br />Codes Info ash <br />Amount <br />Remitted Date <br />Permit/ '` <br />Service Request # Invoice # ell ID# <br />13)$ U <br />L 3 q 1 <br />We 0 2 �s <br />yjca47t <br />0 0101 L42 Sa <br />EBD043-06 1025/2021 Page 1 of 2 Well / Pump Permit <br />