Laserfiche WebLink
I WELL/PUMP PERMIT <br />o o� V� <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLEPERMITGALL <br />ZUV 953-1ti9/ FOR INSPECTIONS <br />t:ArlKt:J I TEAR FROM UATE ISSUED <br />JOB ADDRESS Z t <br />CITY/ZIP <br />/—�/7� <br />I r 1, <br />CROSS STREET �Q <br />OWNER NAME 1]I� <br />yK� <br />1 `�� <br />//y�/ C 1 <br />�/y}()APN {.Y� _��J O- CJI PARCEL SIZE // Q -LAND <br />V 1 <br />USE APPLIICA'TI1(O�J N # <br />10 �Y <br />OWNER ADDRESS 1liV <br />�y� <br />`{ / ^{�,,(� <br />"V t V V v CITYISTATEIZIP <br />(P`HHONE <br />r� <br />WM o V\ IIQ <br />CONTRACTOR <br />1' <br />, I V <br />PHONE <br />CONTRACTOR ADDRESS <br />r& <br />ro CITYISTATErZIP <br />' <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />CITYISTATE/Z1P <br />LICENSE YC -57 C C-61 <br />❑ D-09 <br />❑ Other NUMBER Z <br />ExPIRATtON DATE <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) C! Dibromochloropropane (4392) c_ Arsenic (4393) <br />INTENDED USE mesticJPrivate ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br />❑ Public Water System <br />If dtfferent from Owner. <br />Water System Name <br />contact Name or Plane Number <br />TYPE OF WORK ❑ New Well 1�,Replacement Well ❑ Well Alteration/Modification ❑ Other <br />❑ Monitoring Well s) # of wells ❑ Soil Boring(s) # of bonngs ❑ Geotechnical # of bonny <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />❑ New Pumn ❑ PumD Reolacement ❑ PumD Reoair ❑ Raise Well Casino <br />WELL CONSTRUCTION <br />Drilling MethodMud ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br />Proposed Well epthIt Excavation IV in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Siz in diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched � ❑ Steel Plastic ❑ Stainless Steel 1i Other <br />Grout Seal Depth JW ❑ Neat Cement (94 lb bag/5-10 gal water) n Sand Cement sack mix/7 gal water <br />*"entonite (20% solids) ❑ Other <br />Grout Placement Method )Ppumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal ❑Dimensions: Width ft Length ft Thick <br />lin ❑ Christy Box ❑ Stove Pipe <br />PUMP ❑ Submersible❑ Turbine ❑ Other HP Pump Set ft Standing Water Level It <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 AMV ANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL, (209) 953-7697 <br />DEPARTMENT USE ONLY <br />Application Accepted By 1 Date Area 5 i% Emplo -7 <br />Grout <br />Grout Inspection By ❑ SPECIAL Well Pere, El�r <br />Pump Inspection By Date / iJ ❑ WAIVER Received ""k�"VeD <br />Soil Boring Inspection By Date Constructed Well Depth 4 "' R <br />COMMENTS �`lA ��1`i�C(/� \��it:%.�. %, \ qO 6 L"Z <br />m <br />D <br />0 <br />0 <br />m <br />C•HD043-06 IOf25n021 Pap I art WA / Pump P—.: <br />�9#-138--$86 � Ibvgl� <br />BIS,. ,/f1::���L'l���i <br />C•HD043-06 IOf25n021 Pap I art WA / Pump P—.: <br />�9#-138--$86 � Ibvgl� <br />