Laserfiche WebLink
vi-MAILED -- <br /> I 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 YEAR FRRom DATE ISSUED <br /> .JOB ADDRESS f/�in �n � --- -CrTY/ZIP UGwl' q�J.2V _ <br /> CROSS STREET (/\ ►y�rn'V APN -R PARCEL SIZE LAND USE <br /> r1,'APPAPLICATION FIre <br /> `�j <br /> OWNER NAME !1 1 " �,� J PHONE �t `0 4�� 1"/ �1 <br /> OWNER ADDRESS 20; V 0f �S'`� j� H„ r 'lI CITY/STATE/ZIP C'L11 O �rI)��''/I ✓UyL/ <br /> CONTRACTOR OWMIS I I, fn tPHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATE/ZIP �j. Zs <br /> LICENSE C-57 C-61 D-09 Other NUMBER EXPIRATION DATE 1" �/O sem• <br /> DOMESTIC WELL SAMPUNG:.(General Mineral/Coliform Bacteria(4391))(Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Omestic/Private .- Irrigation/Agricultural CI Industrial -: Water Quality Monitoring CI Soil Sampling/CharacterizatioPHA,ym <br /> Public Water System Rte, NT <br /> Ir different from Ow+ier Water System Name - -C xitad Name or Phone Number <br /> TYPE OP WORK New Well Replacement Well Well Afteration/Modification ❑Other AJAI, <br /> �/ c <br /> Monitoring Well(s) #of wells Sol Bonng(s) #of borin95 I Geotechnical_gyp of bon T 2 <br /> Out-Of-Service Well Out-0f-Service Well Renewal D Cross-Connection Repair 4N Jp <br /> New Pum Pump Replacement Pum Repair D Raise Well Casin ENVI qQU/N C NrY <br /> WELL CONSTRUCTION <br /> �ET;Zfv <br /> Drilling MethodMud Rotary, __ Air Rotary Auger Cable Tool Push Point Other NT <br /> Proposed Well ��ftExcavation IL in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> Cond uctor Casing in diameter / Conduct asing Depth ft <br /> Well Casing D ameterIn Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Li Other ko <br /> Grout Seal D pthft Neat Cement(94 lb bag/5-10 gal water) Sand Cement sack mix17 gal water <br /> ento to(20%solids) a Other <br /> Grout Placement Method Pumped :1Free Fall f i Other Retardant/Accelerator(name) <br /> rmiSTAL Installed By - Dnller '_1 Pump Contractor U Other <br /> ❑ Concrete Pedestal Dimensions:Width ft Length ft Thick <br /> ❑ Christy Box - Stove Pipe <br /> PUMP <br /> 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 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 /> iLKriculture,Industrial well,provide location of any water wells or surface water within 200'radius of proposed well. <br /> MINIMUM 24 H( l R A I)N AN(E NO1 ICE REQL IRF.D FOR INSPE C I H►NS-PI F%SF C kLt-(209)953-7697 <br /> DEPARTMENT USE ONLY _ <br /> Application Accepted By�7 Date A//-7_;: Area Employee ID# FR <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date 1 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth R <br /> COMMENTS �(e-W `mW CS Lgi,,41-e W <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B h Remitted Service Request# <br /> x137 <br /> /SS <br /> X392 42 <br /> - . WdU pump Pumir <br /> EJrDe.}M,IrW„� Page�l�1577a�S l or <br /> C� <br />