Laserfiche WebLink
1 WELUPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS tris EXPIRE�ScI YEAR FROM DATE (ISSUED <br />tJOOSS <br />B ADDRESS 1-75 — � )VQ� ��� 2 J CITY/ZIP / 1 cin <br />MIJP/ l Vi ) J - y <br />STREETI 61 p' D APN Q07dn CSS(7 <br />PARCEL SIZE LAND USE APPLICATION # <br />OWNER NAME _AAL M � n <br />n PHONE <br />OWNER ADDRESS - I 1 75 Ung �/ Ca O�>J 2Q CITY/STATE21PA e - ,,,(AA 0 C A S��O <br />CONTRACTOR p �ro5 jj( <br />ll PHONE( /��Sc7- 050 <br />CONTRACTOR ADDRESS Cp`� O /�}- l �,i b <br />CnY/STATEIZIPy,_IV/l� rP (,^ `5 <br />SUBCONTRACTOR ADDRESS <br />CITYISTATE/ZIP <br />PHONE <br />LICENSE IX -57 ❑ C-61 ❑ D-09 ❑ Other NUMBER 125 1 �D$ EXPIRATION <br />DOMESTIC WELL SAMPLING: C P.nnral <br />v w1w"1w "v'uP1UIld11V t40UZ) L Arsenic (439:3) <br />INTENDED USE ❑ DomestiGPrivate 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 AlterationiModification ❑ Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings ❑Geotechnical # of borings <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />ew Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Qtt1Q <br />Grout Seal Depth ft ❑ Neat Cement (94/b ba9/5-10 gal water) ❑ Sand Cement hh''FA1 TT <br />❑ Bentonite (20% solids) ❑ Other gal water <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />p R. <br />�in <br />EDESTAL Installed By ❑ Driller Pump Contractor ❑ Other <br />,�oncrete Pedestal ❑Dimensions: Width X ft Length ft Thick sn <br />❑ Christy Box ❑ Stove Pipe ENIAL <br />HEALTH <br />PUMP Submersible❑ Turbine ❑ Other HP Pump Set ft Standing Water Level b 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 INSPECTIONS - PLEASE CALL. (209) 953-7697 <br />DEPARTMENT USE ONLY U r <br />Application Accepted By Z_ Date ,id Id L Area l r� c� Employee ID# i (�/� <br />Grout Inspection By Date ❑ SPECIAL Well Permit <br />Pump Inspection By I` a' - �.I Date I �Z-L- ❑ WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS nrl, jt/ .•Je I I Gf f l l� 1 VAI F '() ��Z� Z - y <br />Codes mecSelyvea I Check#/ Amount <br />Info Casf,L Remitted Date <br /># I Invoice # I Well ID# <br />EII0043-06 04/07/2022 <br />1q_'—_1 � Q v / n f / i —­ I of t <br />K (. 1/U� �'`/ J (/ S/ Ij(.j Wcll / Punr Permn <br />I� <br />g <br />0 <br />a <br />M <br />Go <br />