WP0043280 - Laserfiche WebLink

Home Browse Search

I WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 • (209) 468-3420 NUN-KEFUNDABLE P'E/R1M/I-T I�/1 L;ALL (ZUU) `J0J-/by/ FOR INSPECTIONS t1XNIKt_5 1 YE�1ARIFROM DATE ISSUED JOB ADDRESS � J 4 A L-' 1 C'C r c f' -k . -7 CITY/ZIP CL LA" 1 q Ci ;w `-t Jl CROSS STREET_ I 1 w y i-) 1 APN U � 7 -1-70 0 20 PARCEL SIZE `I • S S LAND USE ^A�PPLICATION # v OWNER NAME P� n 9 _e- I �(/� { 1 PHONE Jr Cl r, � �j1 OWNER ADDRESS Sc` M t CITY/STATE/ZIP CONTRACTOR V "1 1 It y 1, 4 i 11 1 ") CONTRACTOR ADDRESS SUBCONTRACTOR PHONE a (_'�i 4'' �� - >{ 7 7q CITY/STATE/ZIP G<1 1 �11 C A � J^ .5� PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP �] Z LICENSE AC -57 1 C-61 ❑ D-09 11 Other NUMBER 2CI C� 3 3 EXPIRATION DATE / — J DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (439 1) Dibromochloropropane (4392) Arsenic (4393) INTENDED USE Domestic/Private i I Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization 1 Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK ;<New Well I I Replacement Well ❑ Well Alteration/Modification ❑ Other A � D Monitoring Wellg# of burin Well(s) # of wells ❑Soil Boring(s) s) ss '7 # of bon Geotechnical ry C1 Out -Of -Service Well 11 Out -Of -Service Well Renewal 11 Cross -Connection Repair 9 09 ❑ New Pum I I Pump Replacement ❑ Pump Repair 0 Raise Well Casing Sq/V WELL CONSTRUCTION HEq T IR�QN �N C Drilling Method %4 Mud Rotary ❑ Air Rotary ❑ Auger :I Cable Tool -1 Push Point ❑ Other Proposed Well Depth ks ft Excavation in diameter a Open Bottom '>K� Gravel Pack/Gravel Size 114 in iarA09r, '1 Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter L_ in Thickness/Gauge/ASTM Sched — �l Steel E( Plastic I Stainless Steel -i Other Grout Seal Depth �7(::, ft 11Neat Cement (94 /b bag/5-10 gal water) Sand Cement—) sack mix/7 gal water 7 Bentonite (20% solids) ❑ Other Grout Placement Method /-.Pumped ❑ Free Fall L Other Retardant I Accelerator (name) PEDESTAL Installed By ')i Driller ❑ Pump Contractor ❑ Other D Concrete Pedestal 'i Dimensions: Width 4 ft Length (11 ft Thick n ❑ Christy Box ❑ Stove Pipe PUMP 1_1 Submersible❑ Turbine r 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 the following 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. NUNIMG l 24 HOUR ADVANCE NOTICE. REQUFRF.D FOR INSPECTIONS - PLEASE CALL (209) 953-7697 DEPARTMENT USE ONLY Application Accepted By �'/� Z — Date 5 l' Grout Inspection By /y Date —7022 Pump Inspection By Soil Boring Inspection By COMMENTS 4v)C Date /r Area N ' Employee ID# t''? ' t� n SPECIAL Well Permit ❑ WAIVER Received Constructed Well Depth ft N m D 0 A N �/v)-y PE SC Received Check#/ Codes Info B Ca h Amount Pate Permit! Invoice # Well ID# Remitted Service Request # 3�g 1S-(7 N3�;r LHDO43-06 04/07'20'_2 Page I oft Nell! Pump Permit