Laserfiche WebLink
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 YEARFROMDATE ISSUED N <br /> / <br /> �y y+� / % �ress 7ZS/� m <br /> Joe ADDRESS / — CITY/ZIP ��`T D <br /> ^2 0 <br /> CROSS STREET /, �` PARCEL SIZ.. )i i 7 LAND USE APPLICATION# <br /> /QST L9c!-%AJAAP OY9—1 �� -- L m <br /> OWNER NAME L��'l.>t i > �✓rt- gel& �j�C vi <br /> OWNER ADDRESSy�`A //��j�d/3,5731 tl �j CITY/STATEIZIPL/#— <br /> CONTRACTOR //��[I/C!/"//'/✓ �t L,.��` v�GL— <br /> CONTRACTOR ADDRESS ZI Z I �Ip,-'o `�J/L CITYISTATEIZIP <br /> SUBCONTRACTOR C.rJ(�� /'Y� �✓ /3��1 PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATEIZIP <br /> LICENSE C-57 C-61 ❑ D-09 ❑ Other NUMBER EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)❑Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE �Domestic/Private ❑ Irrigation/Agricultural tustrial ❑Water Quality Monitoring ❑ Soil Sampling/Characterization Pq <br /> ❑ Public Water SystemContact Name or Phone Number <br /> If different from Owner. Water System Name <br /> TYPE OF WORK'Vew Well ❑ Replacement Well ❑Well Alteration/Modification ❑ Other CD <br /> #of borings ❑ Geotechnical #of boring '1 p <br /> D Monitoring Well(s) #of wells ❑Soil Boring(s) a 7 <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair `S'� py0�/N oC� <br /> ew Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> H�EPgRN NPy <br /> rWELLONSTRUCTIONg MethodArud Rotary ❑ Air Rotary ❑ Auger ❑Cable Tool ❑ Push Point ❑ Other sed Well Depth��ft Excavationin diameter ❑ Open Bottom ravel PacklGravel S ze in diameter <br /> D Conductor asing in diameter / Conductor Casing Depth Casing Diameter-&in Thickness/Gauge/ASTM Sched ❑Steellastic ❑Stainless Steel ❑ Other <br /> Grout Seal Depth LZfl ft ❑ Neat Cement(94 lb bag/5-10 gal water) *Sand Cement &'g sack mixl7 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method umped ❑ Free Fall ❑ Other ❑ Retardant I Accelerator(name) <br /> PEDESTAL Installed By D Driller Pump Contractor ❑ <br /> ❑ Concrete Pedestal❑Dimensions:Width ft ;Other <br /> ength ftThickjn ❑ Ghr'sty Box ❑ Stove Pipe <br /> PUMP ubmersible❑Turbine ❑ Other HPump Set ft Standing Water Level PID 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 /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> I �DEPARTMENT USE ONLY p <br /> Date /� r! <br /> Application Accepted By t/ b Z Area ` Employee ID# A b/ <br /> —I0 Z� ❑ SPECIAL Well Permit <br /> Grout Inspection By Data <br /> Pump Inspection By Date k-L yvstJl O�-� ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth 3q 7 ft <br /> l <br /> COMMENTS <br /> PE SC Received Check#1 Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B ash Remitted Service Request# <br /> �61 v -I- Z3 N 15 <br /> J p � I ZS-L3 0 -71 <br /> -z3 <br /> Page I of 2 Well/Pump Permit <br /> EHD041-0fi 04/07/2022 <br />