Laserfiche WebLink
� AIL. <br /> WELL/PUMP PERMIT <br /> 33 ss <br /> SA I / TNV4RUN NTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE <br /> PERMIT <br /> CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Jos ADDRESS `1 ����. L..1 C tr e r`k C4. CITY/ZIP�C c1i`1;7C' ri 5:_„j :?0 --- m <br /> 1 e /` r D <br /> CROSS STREET AP (JCS 5 (l'1 PARCEL SIZE 4.7 <br /> 1 LAND USE APPLICATION# pA <br /> OWNER NAME a PNONE_�7 1` 4 & ( -7'797 <br /> y <br /> to <br /> OWNER ADDRESS -� l <br /> CITY/STATE171P / ''') <br /> CONTRACTOR �i:�i 'F� 01", t�t �>n �S PHONE4:i'c 77 A'/i ,ilf "��K 7t 71 <br /> CONTRACTOR ADDRESS per (' _ (t�{ L�e� CITY/STATEIZIP �i Zi T , \^i'\ �� ✓ .f <br /> SUBCONTRACTOR, PHONE <br /> SUBCONTRACTOR ADDRESS CITY/ST <br /> ATE/ZIP ] Z <br /> LICENSE )k C-57 C-61 D-09 Other NUMBER , 7 s 7 EXPIRATION DATE <br /> DOMEST1c WELL.SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE ,. Domestic/Pervate Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characteri <br /> Public Water System ��..►► t�• <br /> It different from Owner: Water System Name Contact Nape or PHone Number O <br /> TYPE OF WORK /-New Well Replacement Well :- Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells :. Soil Boring(s) #or borings Geotechnical Sq O ooff borings <br /> -' Out-Of-Service Well Out-Of-Seryice Well Renewal Cross-Connection RepairV/'4O(//N <br /> New Pum Pum Replacement Pum Repair Raise Well Casing HE'g�r/yR NM CpU�ry <br /> WELL CONSTRUCTION <br /> Drilling Method-/,, Mud Rotary Air Rotary Auger. 'l Cable Tool Push Point Other <br /> Proposed Well Depth it Excavation _in diameter i Open Bottom X Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter ! Conductor Casing Depth ft <br /> Well CasingDiameter in Thickness/Gauge/ASTM Sched C ) �a Steel Plastic Stainless Steel i Other <br /> Grout Seal Depth i ft Neat Cement(94/b bag/5-10 gal water) :Sand Cement �� sack mix17 gal water <br /> Bentonite(20%solids) ; Other <br /> Grout Placement Method')�Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By X Driller Pump Contract Other <br /> ' Concrete Pedestal Dimensions:Width ft Length 5 ft Thick <br /> in Christy Box Stove Pipe <br /> PUMP ' Submersible Turbine Other HP Pump Set _it Standing Water Level (1C, 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 properh,lines. For I)omestic, <br /> Agriculture,Industrial well,provide location of any water wells or surface water within 200'radius of proposed well. <br /> D PAR TM ENT US O P LY <br /> Application Accepted B Date O Area Z9 Employee ID# <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By .&A W4"-A? Date /�Z--� WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth_ ft <br /> COMMENjjS well <br /> PE SC Received Check#/ Amount Date PermiU Involve# Well ID# <br /> Godes Info B Cash R mitted Service Request# <br /> `378 Afo Zo S <br /> `7-7 / /SS z3 <br /> d 23 #VD 0 <br /> i <br /> t:N1110,13-01+n4.0_1 2Q2 l'agr1 ,1'2 <br /> well,t'u:m Pmnn <br />