Laserfiche WebLink
11 ` WELUPUMP PERMIT q( -r7. �` v^'' <br />SAN JOAQUIN COUNTY ENVIROUMFNTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCK -TON CA 95205 - (209) 468-3420 <br />NOWREFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROY DATE ISSUED <br />JOB ADDRess /fTCrrdfzr 4, <br />CROSS STREET �4i�e_ kfD n e APN o (0 3 a-70 y 6 PARCEL SIZE t O LAND <br />USE <br />/ICA�TION�%# <br />0VJNER NAME %tV✓IE_Cg J/QQ�C,7— PHONE <br />a,NcRADoRFss AutmIn OelkP) CvSTA7E7AP Sion Op f C) <br />/ , CONTRACTOR /EY &X7/ <br />f <br />PHON!C� �+ �� ✓� / ��/ <br />CONTRACTOR ADDRESS / l" D 4, S ! �W�G _ CITYISTATEIZIP //�LE z�� . �� /✓�Si <br />SUBCONTRACTOR --- PHONE <br />SUBCONTRACTOR ADDRESS CRYISTA7EIZP <br />LICENSE _i C-57 KC -61 Ci 13439 n Other .D :L� NwmER ExPIRATom DATE � 3/ <br />DOMESTIC WELL SAMPLING: D General MinerallColiform Bacteria (4391) O Dibromochloropropane (4392) D Arsenic (4393) <br />IMENDEO USE XDomstcJPdva1e ' Iregation'Agric.1turat _: Industrial llttater GuaKy MonAwing i; So17 SamplrswyChwaeterization <br />Public Water System <br />If d' ferent from Owner. Waver System Name Contact Name or Pbone Number <br />TYPE OF WORK New Well ? Replacement Well G Well MterationtModilication t- Other <br />D Monitoring Wel!(s) # of Wells a Soil Boring(s) u cf bongs Geotechnical # of borings <br />sI OUt4of Service �W`eil is Out-Of-Serwic�e Wed Rermmal C c am apo€* Repafr <br />F New Pump _ f'� anent D Pump Repair Raise in"eN Gasir�g <br />WELL CONSTRUCTION <br />Drilling Method , Mud Rotary i ; Air Rotary ::: Auger i.+ Cable Tool Push Point Other-- - <br />Proposed Well Depth ft Excavation in diameter CI Open Bottom : Gravel PacVGravel Size in diameter <br />' Conductor Casing in diameter I Conductor Casing Depth tt <br />Well Casing Diameter _ in TiiduiesslGaugefASTNI Schee Steel D Piartic Stainless Steel € Cit r_ <br />Grout Seal Depth ft U Neat Cement (94 1b bag/5-10 gal ,.eater) 0 Sand Cement sack mixl7 gal water <br />Bentonite (20% solids) t; Other <br />Grout Placement Method _ Pumped O Free Fall t. Other Retardant f Accelerator (name) <br />PEDESTAL Installed By ' Driller Pump Contractor E Othe: _ <br />D - <br />Concrete Pedestal `:Dimensions= Width It Lelkltr *TN* <br />in 0 Christy Box Stove Pipe <br />Pump n Subrnersibler i Turbine Lr Other HP Pump Set .00 ft Standing Water Level ft <br />Plot Pian 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, eater bodies or cout-,es, drainage pattern, roads, existing wells,, structures, <br />potential sources of contamination, sewers or private disposal systems_ Include distance from two property lium For Domestic, <br />Agriculture, Industrial well, provide location of an water wells or surface water within 2110' radius of proposed well. <br />DEPARTMENT USE ONLY <br />Application Accepted By � � Date /4'z� <br />Grout Inspection By. 4 1 Date of <br />Pump Inspection By Date <br />Sail Boring Inspection By Date — <br />COMMENTS_Doiu,wleni I"oorc Ina 6f we) l <br />ttreaEmp',oy# �1i1 <br />ee ID11 k <br />� <br />❑ SPECIAL Well Permit <br />D WAIVER Received <br />Constructed Well Depth <br />ft <br />PE <br />Codes <br />SC <br />Info <br />Received Checidllt <br />BY Cash <br />Amount !late Permit/ Invoice# WellID9 <br />Remitted rvice Request # <br />1-13 $ <br />o50 <br />- - i WLVU45 30 <br />Ire rain <br />F <br />E <br />'IND ye <br />Z <br />r <br />A <br />EtIM43-06 1025+2021 PzW I oft W�.1' J Pimp i'.are1 <br />