Laserfiche WebLink
'DocuSigr.Envelope ID:66677431-2F71-4Al2-A3FC-083708BE9066 <br /> 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 4CALL(20'9)9�5�3-7697 FOR INSPECTIONS {-EXPIRES <br /> }�I YEAR FROM DATE ISSUED <br /> JOB ADDRESS � ( ✓ �V�'� V *w `' I Y/� CITY/ZIP <br /> M <br /> 1 <br /> D <br /> APN ARCEL SIZE STREET ,�LAND <br /> USE APPLICATION# <br /> OWNER NAME �I-�,1�1Tjil, �t�Vt Sf 4 ` v C/� PHONE <br /> �2�092�9+83069 (�,� y <br /> OWNER ADDRESS � CITY/STATE/ZIPt/l V v� V'q'I /�v—I <br /> CONTRACTOR CC4, "e , 1 �I V � PHONE/1 I,r� •DL.,Dq <br /> CONTRACTOR ADDRESS ��x `�-G�G(0A CITY/STATE/ZIP R I r"31,9 <br /> SUBCONTRACTOR ��/ PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE -57 Ll C-61 lJ D-09 Ll Other NUMBER EXPIRATION DATE DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE 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 New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings <br /> Li 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 Mud Rotary ❑ Air Rotary El Auger C Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well DepthIt 0 ft Excavation in diameter ❑ Open Bottom XGravel Pack/Gravel Size in diameter <br /> Ll Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched a Steel A Plastic J Stainless Steel u Other <br /> Grout Seal Depth.Ij7 ft u Neat Cement(94 lb bag/5-10 gal water) a Sand Cement sack mix/7 gal water <br /> �Oentonite(20%solids) L_ Other <br /> Grout Placement Method 2Tumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By -i Driller ❑ Pump Contractor ❑ Other <br /> I Concrete Pedestal FJ Dimensions:Width ft Length ft Thick <br /> �in _I Christy Box LI Stove Pipe <br /> PUMP ❑ Submersible❑ Turbine ❑ Other HP Pump Set ft Standing Water Level ft <br /> Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the f q vh%F,%My <br /> Coordinates, property lines, adjoining properties, water bodies or courses, drainage pattern, roads, existiC �5 <br /> potential sources of contamination, sewers or private disposal systems. Include distance from two property Ines. or 0 ,T <br /> Agriculture,Industrial well,provide location of any water wells or surface water within 200' radius of proposed well. <br /> MININIt NI 24 1101 R AI)N A N(T NO"I1CF1 RLQI IRIA)FOR ISSPF.("I IONS-11I,11ASt;CALL(209)953_769' <br /> } DEPARTMENT USE ONLY �� ,, ,� <br /> Application Accepted By / Date Area Employee ID#�� <br /> Grout Inspection By DateJ2n1J-N 101-' ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS y2C'�Iyy A <br /> PE Sc Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info Cash Remitted Service Request# <br /> L) a 412/2_3 �E�t mal <br /> 3(► <br /> EHD043-06 04/07/2022 Page I of 2 Well/Pump Permit <br />