Laserfiche WebLink
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 CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FR6m DATE ISSUED <br /> �ftyu 9SztZ <br /> JOB ADDRESS CITY/ZIP m <br /> p �Ja D <br /> CROSS STREET /�/., �/ /�//J/�i�/C APN 123L-7LL) " 107-PARCEL SIZE LAND USE APPLICATION# <br /> m <br /> 2s <br /> OWNER NAME <br /> PHONE AW-9-507N <br /> OWNERADDRESS L✓�{S �3 L/—� CITY/STATE/ZIP Pat <br /> Q/1F�ZA-�_�y� <br /> CONTRACTOR /� A�L� L C PHONE <br /> �/ <br /> CONTRACTOR ADDRESS /i-1�® �I�._Gv� /�J_/ CITY/STATE/ZIP <br /> SUBCONTRACTOR �/ � ✓fiy,�/✓Cy PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE )OC-57 ,IVC-61 ❑ D-09 ❑ Other NUMBER EXPIRATION DATE 31 <br /> Z <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)❑ Dibromochloropropane(4392) . Arsenic(4393)p <br /> INTENDED USE omestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Chara J k <br /> ❑ Public Water System ��r��VPft <br /> i_If,different from Owner: Water System Name Contact Name or Phone Numb <br /> TYPE OF WORK 1 Pew Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other - <br /> /❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical Of pfings <br /> �Y C <br /> ell 0 <br /> ❑ Out-Of-Service❑ Pum Replacement ❑ PumRepair O ice Well Renewal ❑ Raise Well Casing Repair i,TN FPgRTTq` 7Y <br /> WELL CONSTRUETION <br /> Drilling Method>OMud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth zso ft Excavation 12—_ in diameter ❑ Open Bottom AlMravel Pack/Gravel Size in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter—46?in Thickness/Gauge/ASTM Schad Gy2Bfl ❑ Steel JWPlastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth &/1 ft ❑ Neat Cement(94/b bag/5-10 gal water) ❑ Sand Cement sack mW7 gal water <br /> Bentonite(20%solids) ❑ Other <br /> Grout Placement Method Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller VPump Contractor ❑ Other <br /> ❑ Concrete Pedestal❑Dimensions:Width ft Length ft Thick <br /> in ❑ Christy Box ❑ Stove Pipe <br /> PUMP >OSubmersibleo Turbine ❑ Other HP Pump Set ft Standing Water Level <br /> Plot Plan R quirements: 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 /> �j MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> DEPARTMENT <br /> Us O LY a <br /> . Application Accepted By Date < Area Employee ID# <br /> `, Grout Inspection By Date l /4 1 Z 3 SPECIAL Well Permit <br /> 7 Pump Inspection By Date WAIVER Received 7 �} t <br /> Soil Boring Inspection By Date Constructed Well Depth Ei1S ft <br /> COMMENTS Am — (0 Ct 12, t,i-✓ <br /> r � <br /> PE SC Received Chec Amount Date Permit/ Invoice# Well ID# <br /> Codes Info Pas Remitted Service Request# <br /> X (0 4`5�20 c( 2m123 w (PCD Lkqtlbs <br /> Y3 9/ /SS I 1 <br /> y��O .0157 /lo Z 9 Zfo12'3 c„W?Q& S So <br /> EHDO43-06 04/07/2022 Page I of 2 Well/Pump Permit <br />