Laserfiche WebLink
• ,L" Well �3 6� <br /> 1' WELL/PUMP PERMIT <br /> 'SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT JCALL 209 953-7697 FOR INSPECTIONS EXPIRES�I Y,EAR FROM DATE ISSUED <br /> /12-56 Al �L ke 4&.rte CITY/ZIP G6d/ 41 4�t yV M <br /> :::TR:ss � <br /> m hID,B QG - /yEET APN oJ� ��'[/(O'/ PARCEL SIZE � LAND USE APPLICATION# o <br /> L // N <br /> OWNER NAME ..�►'In �(T 2 /' PHONE 201 7,63- �3to <br /> OWNER ADDRESS 2S2 �p�p.Q Cre r (L tul CITY/STATE/ZIP LOU/ Gn . �SLyy <br /> CONTRACTOR PHONE w/ -77 7i' 2 Z s-7 <br /> CONTRACTOR ADDRESS 4� U Jako(/7 7 I CITY/STATE/ZIP elo <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/S-10 <br /> T7ATE/ZIP <br /> LICENSE -57 ❑ C-61 ❑ D-09 ❑ Other NUMBER 10171070 EXPIRATION DATE �P' <br /> Doluesric WELL SAMPLING:❑General Mineral/Coliform Bacteria (4391)❑ Dibromochloropropane(4392)❑Arsenic(439 <br /> INTENDED USE KDomestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Chard t AI� <br /> ❑ Public Water System R �t*i �11 <br /> If different from Owner. Water System Name Contact Name or Phone Number _ 'tU <br /> TYPE OF WORK [)(New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ OtherJul , *A <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical SA #of bori I/I <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair NV/RpU//V COVN <br /> New Pum ❑ Pum Re'lacement EJ Pump Repair ❑ Raise Well CasingTHD NMEN7AL <br /> WELL CONSTRUCTION MSIVT <br /> Drilling Method )'Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth Sao ft Excavation in diameter ❑ Open Bottom if Gravel Pack/Gravel Size in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter 6 in Thickness/Gauge/ASTM Sched 5042/ ❑ Steel ()(Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth Z00 ft ❑ Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement_/6 -3 sack mix/7 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method 'Pumped ❑ Free Fall ❑ Other El Retardant/Accelerator(name) <br /> PEDESTAL Installed By YDrlller ❑ Pump Contractor ❑ Other <br /> ❑ Concrete Pd(destal❑Dimensions:Width ft Length ft Thick <br /> in ❑ Christy Box ❑ Stove Pipe <br /> PUMP ubmersible❑ Turbine ❑ Other HP Pump Set / V ft Standing Water Level <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 /> NIININIUNI 24 HOUR ADVANCE NOTICE;REQUIRED FOR INSPFCTIONS-PLEASE CALL(209)953-7697 <br /> C DEPARTMENT USE ONLY r' <br /> Application Accepted By !� Date 7 a7 F Area Employee ID# 4rtk <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS We,)) 3':c weirs k a y .0 p u l L W ei4er - <br /> PE SC Received (`ChecW Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B ash RpmitJedKJ Service Request# <br /> 4320 Ds-I 2 Iss6 <br /> 366190 0 L4 I <br /> 3aa #7 6 <br /> as <br /> EHD043-06 10/25/2021 Page I of2 Well/Pump Permit <br />