Laserfiche WebLink
r <br /> y EMAILED <br /> 1 <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 -(209)468-3420 <br /> NON-REFUNDABLE PERMIT {� d CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1/lYEAR <br /> /FROM <br /> �DATE ISSUED <br /> JOB ADDRESS �?3De, 6. 8 t)l�liI1QAJ y / {� CITY21P ��&-4-Lp-d/ <br /> CROSS STREET 1y`k- leo ko APIN A77-2CJ9'P-1JD-ODDPARCEL SIZE 3 65_LAND USE APPLICATION# O <br /> OWNER NAME RagE1P�pN /e,�,/u� DIE(/, LLL PHONE(;�pq)%Q6 -`A/2Z- U5i <br /> OWNER ADDRESS _�J 3O J�/s��E /j Lt/P CITY/STATE/ZIP/4441A)4 t l}LL/�/ypr/ oI?gv-5107 <br /> (�/f <br /> CONTRACTOR '1L1,qI k�,^ N b �G.. - PHONE O`�'%� •7-✓ /7 <br /> CONTRACTOR <br /> CONTRACTOR ADDRESS T 3 D�'ye-s T-t�` CITY/STATEIZIPu <br /> SUBCONTRACTOR ��� PHONE <br /> SUBCONTRACTOR ADDRESS �`C/�ITY/STATE/ZIP ly <br /> LICENSE XC-57 0.0-61 D D-09 D'Other NUMBER 7;Z 9-7e EXPIRATION DATE 31 �ap;7 <br /> DOMESTIC WELL SAMPLING:G General Mineral/Coliform Bacteria(4391)0 Dibromochloropropane(4392)GArsenic(4393) <br /> INTENDED USE D"Domestic/Private rrigation/Agricultural ti:Industrial q Water Quality Monitoring O;Soil Sampling/Characterization <br /> O Public Water System <br /> If <br /> different <br /> TYPE OF WORK NewWellrom Owner. Water <br /> Well 0 Well Alteration/Modification O-Other Contact Name or Phone Number Y/11 <br /> D.MonitoringWell(s) 4o wells DSoilBoring(s) #ofborings ❑ Geotechnical #ofborings `/V�� <br /> D Out-Of-Service Well O,Out-Of-Service Well Renewal O'Cross-Connection Repair Ai �D <br /> 0 New Pum D Pum Replacement D.-Pump Repair D-Raise Well CasingfYov <br /> WELL CONSTRUCTION "�7 <br /> 2O <br /> qN�0 23 <br /> Q �¢.QS£ r.3 q <br /> Drilling Method O:Mud Rotary O,.Air Rotary 0:-Auger ❑"Cable Tool ❑:Push Point O,;;Other^e �j f�-�ENVI,o�` IN C <br /> Proposed Well Depth QO ft Excavation o�(o In diameter 0 Open Bottom 0,Gravel Pack/Gravel Size -irl d�� gwl E/�fTq�NTY <br /> Conductor Casing Xy" in diameter / Conductor Casing Depth .SGp ft gRTNj�cNT <br /> Well Casing Diameter A—in Th kness/Gauge/ASTM Schad 7�� U&Steel ❑ PT lastic O`Stainless Steel 0`:0ther <br /> Grout Seal Dgpth X241 D.Neat Cement(94/b bag/5-10 gal water) 1,�'Sand Cement /�, sack mixf7 gal water <br /> ���• �VGt'�`l'���Bentonite(20%solids) ❑ Other <br /> Grout Placement•Method Pumped ❑ Free Fall D,Other D Retardant/Accelerator(name) <br /> PEDESTAL�Installedriller Pump Contractor � Othertal DDimensions:Width ft Length ft Thick <br /> in Stove Pipe <br /> PUMP o Zubmersible�(Turbine D Other HP Pump Set ft Standing Water Level 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 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 INSPECTIONS-PLEASE CALL(209)953-7697 <br /> ��DE�PARTMENT U E NLY C <br /> Application Accepted 8 Date �� S Z Area 99 Employee 1D# AS <br /> Grout Inspection By Date 2 7, ❑ SPECIAL Well Permit <br /> Pump Inspection By Date a 'WAIVER Received <br /> Soil Boring Inspection By Date Cons ructed Well Depth it <br /> COMMENTS _ — ZZ <br /> 2 I n Cltux { <br /> PE Sc Received Check#/ Amount Permit/ <br /> Codes Info By Cash Remitted Date Service Re uest# Invoice# Well ID# 1 p7 <br /> Zo1 oo So o <br /> EFID047.06 04107/2022 ,/- Page I of 2 %ZA <br /> 1 •13 — ,•L�(• �� 1.L 1•w• j <br /> u i rung peoaa <br /> 17L <br />