Laserfiche WebLink
EMAr1LED <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 CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM r DATE ISSUED <br /> F�_�AG`n (� to <br /> JOB ADDRESS Vmr) M CrrY/ZIP MEGA V 'i <br /> m <br /> CROSS STREET �MIM1 APN PARCEL SIZE LAND USE APPLICATION# O <br /> m <br /> ,OWNER NAME 'S 1f" -�,r�-S ,�1 PHONE <br /> .'OWNER ADDRESS 0. <br /> }� CITY/STATE/ZIP �r1� <br /> CONTRACTOR I 1" I ( PHO�NEE ZOO 4 ( 117-0 <br /> ,CONTRACTOR ADDRESS ' I t/ V t�`J CrTYISTATE/ZIP 0jLl.(1M N fl�/ S7 J <br /> (SUBCONTRACTOR 'N, � ' l PHONE <br /> SUBCONTRACTOR ADDRESS CrrY/STATE/ZIP <br /> i <br /> LICENSE C-57 C-61 D-09 Other NUMBER A — EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> F <br /> INTENDED USE Domestic/Private Irrigation/Agricultural C Industrial Water Quality Monitoring ! Soil Sampling/Characterization /1 <br /> Public Water System ^t s <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 CO <br /> Monitoring Well(s) #of wells Soil Boring(s) a of borings Geotechnical #ofbo i 0 <br /> _ Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair SAN J Zjr <br /> New PumpPump Replacement _ Pump Repair Raise Well CasingE Oq QU <br /> WELL CONSTRUCTION CTN DE qRT l�� <br /> Drilling Method�lud Rota Air Rotary _ Auger Cable Tool Push Point Other NT <br /> Proposed Well Depth_bl-ft Excavation _JC� in diameter Open Bottom .Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter ! Conduct r Casing Depth ft <br /> Well Casing Diameter_11 in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br /> Grout Seal �GQ3 _ Neat Cement(94 Ib bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> Bentonit (20°ro solids) Other <br /> Grout Placeme�epth <br /> ethod umped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> i_ Concrete Pedestal Dimensions:Width ft Length ft Thick <br /> lin Christy Box Stove Pipe <br /> PUMP Submersible: Turbine Other HP Pump Se, If 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 eater wells or surface water within 200'radius of proposed well. <br /> \l!\l�t131.�HUIN:�U\ASCL\UT1CL I:£Ol tKt.0 FUR I\�F'I:.( I It/\5-;'1_t::>,SE C:1LL tZOv)v�3-%bl- <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date 2/(a Area 9 Employee ID# S <br /> Grout Inspection By -- Date fs _ SPECIAL Well Permit <br /> Pump Inspection By Date 0 12S 2,57 WAIVER Received <br /> CT Soil Boring Inspection By Date Constructed Well Depth R <br /> N COMMENTS Fee/4 WG/�. S t � z r.r„r� rc' •u,i.� �1+�. <br /> .9 O 0 , <br /> PE Sc Received Check#/ Amount Date Permit/ Invoice# Well IDS <br /> Codes Info B Cash Remitted Service Request# <br /> 36 I o 0 25 (o l <br /> EHDO43-06 0•tiomo2'_ / 'S_7372q?gageJ I oft Well;Po rn Pump Pna <br /> D v M-f T ��(ft►Lu 'C� �� � to ,per C-Vt*— Tl kH?Z4 _ <br />