Laserfiche WebLink
rt ' <br /> ,y 1 EMAILED WELL/PUMP PERMIT <br /> SAN JO,AouiN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205- (209)468-3420 <br /> N 25451 <br /> C p CALL 209 953-7697 FOR INSPECTIONS f�EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS .�(5 q J 1 N V M�9 Yl l0�'b,�ei t�r2 1 Gl C e Cn7/Z1P /\C c',r k'(' ( A Ch7 <br /> CROSS STREET C e''l) l P r R T7. APNO,05—*0 04?-PARCEL <br /> PARCEL SIZE LAND USE APPLICATION# A <br /> OWNER NAME Tc1 1'1 t' ••� PO,n r4 C __.._._._ PHONE <br /> OWNER ADDRESS \I :5*^'"e. CITYISTATE/ZIP (, <br /> CONTRACTOR V Lr' <br /> t K 1 ?0 : I �` , rl �l PHONE 20 3(-9 - 2-771 <br /> (-9 - 2� <br /> —7p <br /> CONTRACTOR ADDRESS �'/ 13 CJ( _ CITY/STATE/ZIP_ CA { S;(, 3-7 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS C^I�TY/SITATE//ZICP /� <br /> LICENSE ')(C-57 C-61 i-t D-09 Other NUMBER JAI�! 38.5 EXPIRATION DATE 7'aq —Dq <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE '$.Domestic/Private Irrigation/Agricultural Industrial -i Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells -_ Soil Boring(s) #of borings Geotechnical re of borings <br /> Out-Of-Service Well Out-Of--Service Well Renewal Cross-Connecfion Repair <br /> New Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method�K Mud Rotary Air Rotary i Auger ..1 Cable Tool Push Point Other <br /> Proposed Well Depth q45 It Excavation in diameter I Open Bottom )k Gravel Pack/Gravel Size /q - in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter f1-- in Thickness/Gauge/ASTM Sched C\ �?t� Steel )<Plasbc 7 Stainless Steel Other <br /> Grout Seal Depth I t O ft Neat Cement(94 Ib bay/5-10 gal water) X Sand Cement It' _� sacrt AYMENTer <br /> Bentonite(20%solids) Other RECEIVED <br /> Grout Placement Method )k,Pumped Free Fall Other 1 Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other jul <br /> )(Concrete Pedestal (Dimensions:Width q ft Length it Thick GOUXTY <br /> in Christy Boz Stove Pipe s E' vIRONMAL <br /> N. <br /> f• <br /> PUMP ,Submersible Turbine Other HP Pump Set--V. c ft Standing Water Level C C• ft <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 /> PARTMENT US ON Y <br /> 2 �j C /�y1 <br /> Application Accepted By Date <br /> _7Z <br /> Z Area _!1 Employee ID# A • <br /> Grout Inspection By. Al Date b>L--I--L3 SPECIAL Well Permit <br /> Pump Inspection By Date--2--13——If. WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth_ �.� ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permitl Invoice# Well ID# <br /> Codes Info h Remitted Service Request# <br /> - ' Z-t� *13\\2 <br /> Y914 �Scs <br /> ,v <br /> aS7 2 "�I3\\23 Wpm �1� <br /> ttuxl43-06oa'oz?n.' / � ^ ���j�11rn�.�I or well Yump Permit <br /> V Y <br /> C�} <br /> 95-Z ya <br />