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 209 953-7699'7/FOR INSPECTIONS EXPIRES 1 YEAR <br /> dFROM <br /> /�DATE ISSUED <br /> JOB ADDRESS 25�q / e,�nl�iae� /Y/ CITY/Zip jrpiPrf>� �/T % .,5r garl m <br /> CROSS STREET //•/�n /A/F1^'/ APN Old 3 i a 0 06 PARCEL SIZE�C('�� LAND USE APPLICATION# <br /> OWNER NAME /�`�j� T C1 P eS PHONE <br /> , / /1 <br /> OWNER ADDRESS 25Z9 / A �C r/7k, _( 12W CITY/STATE/ZIP lft,045 eA <br /> CONTRACTOR r��\ prtiuIVI1 1 (. '/ PHONE 2017 772 -``75-7 <br /> CONTRACTOR ADDRESS r/I/ 60A /�2�// CITY/STATE/ZIP eAlj`y lv/tlMry.2 "/ ✓Z7 � <br /> SUBCONTRACTOR PHONE TTT <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C-57 ❑ C-61 ❑ D-09 -' Other NUMBER IJ91701 EXPIRATION DATE 3/- ?GLL <br /> DOMESTIC WELL SAMPLING:General Mineral/Coliform Bacteria(4391)❑ Dibromochloropropane(4392)❑ Arsenic(4393) <br /> INTENDED USE X Domestic/Private '❑ Irrigation/Agricultural _ Industrial ❑ 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 II[New Well Replacement Well Well Alteration/Modification Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> New Pump ❑ Pump Replacement ❑ Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method A Mud Rotary ❑ Air Rotary ❑ Auger Cable Tool ❑ Push Point Other <br /> Proposed Well Depth 3G0 ft Excavation /7 �i in diameter i Open Bottom ?Gravel Pack/Gravel Size jp T <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft RECEIV Well Casing Diameter 1� in Thickness/Gauge/ASTM Sched < Z k I ❑ Steel X Plastic ❑ Stainless Steel n Other <br /> Grout Seal Depth /a ft Neat Cement(94/b bag/5-10 gal water) R Sand Cement 112.7 sack mix/7 gal water <br /> ❑ Bentonite(20%solids) Other ;-��4i 22 <br /> Grout Placement Method A Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> NTY <br /> PEDESTAL Installed By X Driller ❑ Pump Contractor ❑ Other FNVIRO MF 1AL <br /> ❑ Concrete Plidestal❑Dimensions:Width ft Length ft Thick HFAI TH nFPAR IAENT <br /> �in ❑ Christy Box ❑ Stove Pipe <br /> PUMP Submersible❑ Turbine ❑ Other HP_J6'_ Pump Set Z L. ft Standing Water Level iys 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 /> MININIUNI 24 HOl'R kDN'kNCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> DEPARTMENT*�11 -- F ONLY <br /> Application Accepted By �_�Z� Z_ Date al'� `f za Area L� Employee ID# <br /> Grout Inspection By qs19 Date �&j22, ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS FA)s I i yt/� ,l P�� �PT9']c 1 i, <br /> PE SC Received Check#/ Amount ate Permit/ Invoice# Well ID# <br /> Codes Info Cash Remitted P Service Re quest# <br /> 4390 OS' 1 -�Isa <br /> 3-79 180 WOIva 01, <br /> L3e11 /50 It <br /> EHD043-06 10/25/2021 Page I or2 13 1 / Well/Pump Permit <br />