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 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS .l / /. '[/I� Y1 CITY/ZIP AICAya�� C-4J ;Lat,' m <br /> �/ L�- D <br /> CROSS STREET `�, p /�^ APNW I `: a� I -f PARCEL SIZE l LAND USE APPLICATION# <br /> OWNER NAME LA n i'Cr 1/C u lnt t f `L �I L f-��` PHONE y <br /> OWNER ADDRESS �QQGA V' <br /> j� •� / CITY/STATE/ZIP <br /> CONTRACTOR 4JI PHONE p/ o (.,k, J V <br /> 'y <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP LC1 ` �� 1 <br /> 'nVN k—.ZV <br /> SUBCONTRACTOR /fit PHONE <br /> SUBCONTRACTOR ADDRESS C�I`TYY/�$(TA�TE/ZIP—1 <br /> LICENSE C-57 L C-61 J D-09 J Other NUMBER 1 1 I EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring J Soil Sampling/Characterization <br /> 7 Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK J New Well Replacement Well J Well Alteration/Modification J Other <br /> J Monitoring Well(s) #of wells J Soil Boring(s) #of borings J Geotechnical #of o VE <br /> J Out-Of-Service Well J Out-Of-Service Well Renewal -i Cross-Connection Repair <br /> J MAY ' <br /> New Pum ❑ Pum Replacement _J Pum Repair J Raise Well Casing <br /> WELL CONSTRUCTION SAN JOq <br /> Drilling MethodU"MUd Rotary ❑ Air Rotary J Auger El Cable Tool :1 Push Point 11 Other ENV QU/N C <br /> Proposed Well Depth 3C U ft Excavation t;l_ in diameter J Open Bottom A Gravel Pack/Gravel Size1LT H-`11 er <br /> Conduct r Casing in diameter / Conductor Casing Depth ft TMEN <br /> Well Casing Diamete in Thickness/Gauge/ASTM Schedsa�1 J Steel XPlastic -i Stainless Steel -i Other <br /> Grout Seal Depth�ft ❑ Neat Cement(94 Ib bag/5-10 gal water) _1 Sand Cement sack mix17 gal water <br /> A Bentonite(20%solids) ' Other <br /> Grout Placement Method Pumped ❑ Free Fall 7i Other 7 Retardant/Accelerator(name) <br /> PEDESTAL Installed By J Driller ❑ Pump Contractor ❑ Other <br /> 7 Concrete Pedestal:Dimensions:Width ft Length ft Thick <br /> �in -i Christy Box ❑ Stove Pipe <br /> PUMP 7 Submersible-1 Turbine it 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 /> Agriculture,Industrial well,provide location of any water wells or surface water within 200' radius of proposed well. <br /> \11N111t N1 24 1101 R 1DVANCE NO'FICF.RLQt IRHD FOR INSI'LC-1 IONS-PI,EASE CAI.t.(209)953-?69? <br /> �Q DEPARTMENT USE ONLY / q' <br /> Application Accepted By / <br /> '5 <br /> Date — 1,- 7-j Area 0 Employee ID# KJ { <br /> Grout Inspection By k" `tf `L Date C SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS 0c- iK _ ✓' 5 K '(4 ( 1-4 <br /> L c./�P �E��1- �3s�N t.A. ham• r <br /> PE Sc ReceivedCheck#/ Amount Date Permit/ Invoice# Well ID# <br /> Code Info B Remitted ' Service Request# <br /> i t 2ers wt��c� s� <br /> EHD043-06 04/07/2022 Page I of 2 Well/Pump Permit <br />