Laserfiche WebLink
i WELL/PUMP PERMIT <br /> SAN JOAom COUNTY EMVIRONwEwrAL HEALTH DEPARTMENT I BBS EAST HAZELTori AVENUE-STOCKTON CA 95205 - (209)468.3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESSQ� 1-ZMZ2- K- NVS PA CrrYJZp mVl �a <br /> IVm <br /> CROSS STR19Er V Y• APN LC; - 1 O U O O PARCEL S¢E g�LAW USE APPucATM# g <br /> OwNEit NAME <br /> n ti s PJiONE � . <br /> OWNER ADDREn 111 IF, 'MON G�f- / 12A Cm,STTATE,aP yMfflL A Ci <br /> CONTRACTOR M S Dr I N u G - PHONE <br /> CONTRACTOR ADDRESS CrfY1STATEfZ 1r{D A 'l! ' <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS Cnlr/STATEMP <br /> LJCENSE XF757 ❑ C-61 D D-09 ❑ Other NUMBER ExmRAnoN DATE / <br /> Dommm WELL SAWING:❑General Mineral/Coliform Bacteria(4391)C Dibromochloropropane(4392),;;Arsenic(4393) <br /> INraJtx=O USE ❑ Domestic/Privatertigabon/Agricullural 13 Industrial 11 Water Quality Monitoring ❑ Soil Sampfing/Characterization <br /> El Public Water Syst <br /> It ditTerert ham Owner. Water System Name Conted Name or Phone Number A' <br /> TYPE OF WORK ❑ New Well >teplacement Well ❑Well AlteratioNModification ❑ Other �O <br /> O Monitoring well(s) #of wells ❑ Sol Boring(s) tt of bonrgs ❑ Geotechnical #of <br /> U Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair SAN 08 ? <br /> D New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well CasingE `24- <br /> WELL CONsTRUCnON T 11 CO <br /> Drilling Method Mud ❑ ❑ <br /> Air Rotary Auger Cable Tool ❑ Push Point F] Other <br /> N�Fpq FNr TY <br /> Proposed Well thd�ft Excavation in diameter ❑ Open Bottom Vravel Pack/Gravel Size in diame T <br /> ❑Conductor ing in diameter / Cond�j�o.r Casing th ft <br /> Well Casing Diameter in ThicImesslGauge/ASTM Sched_-r-- Steel 0 Plastic ❑ Stainless Steel U Other <br /> Grout Seal Eft ❑ Neat gement(941b bag/b-10 gal wat ❑ Sand Cement sack mixl7 gal water <br /> rtonite(20%solids) ❑ Other <br /> Grout PI Method Pumped ❑ Free rail ❑ Other D Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Drdler D Pump Contractor D Other <br /> ❑Concrete Pedestal❑Dimensions:Width ft Length ft Thick <br /> lin ❑Christy Box C Stove Pipe <br /> 1!yMp ❑ Submersible❑Turbine ❑ Other HP Pump Set ft Standing Water Level ft <br /> Plot Plan Requirements: Attach a pkat 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 INSPEC-nONS-PLEASE CALL(209)953-7697 <br /> DEPARTMENT USE ONLY G tp <br /> APPS AcceptedBy �iG Date 07AL3 Area 5 / Employee ID# F'\ <br /> Grout Inspection By r 1 C V ! Date i )' ❑ SPECIAL Well Permit <br /> Pump Inspection By Date 0 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENT'S 4Je11 pJaldrnfe C Pxew+,'✓e or r N-7--a2 Cam loll Gklz49 <br /> 1 - <br /> PE SC Receh►sdi ChedW Amount Dabs WnnW Invoice,II Weu of <br /> Codes IRfo cash Rest~ s <br /> 30 IWO yeti 2 G . <br /> r <br /> Q <br /> EHDO434604,U7a922 t rorz w�u e«ma <br />