Laserfiche WebLink
EMAILED <br /> 1 58 WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON C A 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS �_�J � ' •� KVJ" 7- ,l CITY/ZIP �' C � � I m <br /> CROSS STREET n �'rl '� APN �07 3X'9 Z- RCEL SIZE ' 0 LAND USE APPLICATION# CI <br /> OWNER NAME c,1'' (A c t_PHONEE., (�� 1 c, /f)"I% m <br /> OWNER ADDRESS \-I, ! I / 7 ( 1 ! I-yhc rC "f Or, CITY/STATE/ZIP C.yl�lt.-Y 1 C lckI me tip 3 17 <br /> CONTRACTOR V� C f l ! n �( PHONE ✓)�/�� C. t�'�%�7 377.1I <br /> CONTRACTOR ADDRESS (j C' .11`. CITY/STATEIZIP ('rte (14 -t J ? <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP �7 1 L� <br /> LCENSE ` C-57 C-61 D-09 Other NUMBER 2 r C S ExPIRATION DATE / - f ` <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391))(Dibromochloropropane(4392)X Arsenic(4393) <br /> INTENDED USE Domestic/Private Irrigation!Agricultural Industrial Water Quality Monitoring . Soil Sampling/Characterization <br /> Public Water SystemNr <br /> If different from Owner Water System Name Contact Name or Phone Number <br /> TYPE OF WORK x New Well Replacement Well Well Alteration/Modification Other RECEIVED. <br /> Monitoring Well(s) #of wells - Soil Boring(s) N of borings Geotechnical 0 of borirMAY 17 2023 <br /> Out-Of-Service Well Out-Of-Service Well Renewal - Cross-Connection Repair <br /> New Pump Pump Replacement Pump Repair Raise Well Casing SAN JOAQUIN COUNTY <br /> WELL CONSTRUCTION <br /> HEALTH DMPARTMENT <br /> Drilling Method'>(Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br /> i <br /> Proposed Well Depth 3A Excavation 12, in diameter Open Bottom >(Gravel Pack/Gravel Size !fg- in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter-C-1- in ThicknessiGaugeiASTM Sched Steel >(Plastic Stainless Steel Other <br /> Grout Seal Depth 1( L ft Neat Cement(94 Ib bag15-10 gal water) )< Sand Cement�G 7 sack mix17 gal water <br /> Bentonite(20%solids) Other <br /> i <br /> (Grout Placement Method Pumped Free Fall Other Retardant i Accelerator(name) <br /> 1PEDESTAL Installed By Driller - Pump Contractor Other <br /> X Concrete Pedestal Dimensions Width L_ft Length ft Thick <br /> kn Christy Box Stove Pipe <br /> Pump )(,Submersible Turbine Other HP Pump Set yl. ft Standing Water Level_1�2C' 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 %cater wells or surface%%iter within 200'radius of proposed well. <br /> DEPARTMENT US y O,N LY <br /> Application Accepted B Date Area Employee/ Employee ID#� <br /> Grout Inspection B _ Date����uSPECIAL Well Permit <br /> Pump Inspection B � Date ��/ [�2.3 WAIVER Received <br /> Soil Boring Inspection fay Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Ste Permit/ Invoice# Well ID# <br /> Codes Info Cash A Remitted Service Request# _ <br /> ss' <br /> & <br /> oo <br /> 2,1 <br /> LIIfNU�-(M tN -- Pagr:n(_ /�� N'cll f9+rtq.I'umn <br />