Laserfiche WebLink
rsM Pw+� ��iN•i f <br /> i <br /> DocuSign Envelope ID:AF649087-858C-4B57-AB87-13A8EE592594 <br /> 1 M WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-WO <br /> NON-REFUNDAB E P RMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRE-iTS <br /> I YEAR FROM DATE ISSUED <br /> Jos ADDRESS � tV CrTYIZIP �1V L IS-►r I� <br /> iOlt CROSS STREET �� ` AP L SIZE ND USE APPLICATION# <br /> \ In <br /> L/ In <br /> OWNER NAME r/V PHONE Y'ii <br /> OWNER ADDRESS CITY/STATEIZIP <br /> CONTRACTOR t I PHONE i V <br /> CONTRACTOR ADDRESS x CITY/STATEIZIP (Alw� V t <br /> SUBCONTRACTOR 1 t PHONE <br /> SUBCONTRACTOR ADDRESS CITYIS AT <br /> LICENSE 57 L C-61 _ D-09 Other NUMBER XPIRATION DATO <br /> DOMESTIC WELL SAMPLING:�NGeneral Mineral/Coliform Bacteria(4391)�Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE X- 110mestic/Private Irrigation/Agricultural C. Industrial D Water Quality Monitoring E Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK flew Well _ Replacement Well = Well Alteration/Modification G Other <br /> Monitoring Well(s) #of wells Soil Boring(s) #of borings Geotechnical -, NT <br /> Out-Of-Service Well " Out-Of-Service Well Renewal Cross-Connection Repair VFW <br /> New Pump Pump Replacement = Pump Repair C Raise Well Casing <br /> WELL CONSTRUCTION ✓ �D?? <br /> Drilling Method�Muddd 0 Air Rotary Auger L Cable Tool Push Point L Other OAQ <br /> Proposed Well Depth � l 1 ft Excavation in diameter Open Bottom ravel Pack/Grav N (/Adl$rneter <br /> Conduc r Casingin diameter Co� cat yCasin De th ft Aftif <br /> Well Casing Diameter in Thick ness/Gauge/ASTM Schec�-l-�L) -RSteel ;Wlastic Stainless Steel F Other NT <br /> Grout Seal Depth ft - Neat Cement(941b bag'5-10 gal water) Sand Cement sack mrx17 gal water <br /> entonite(20%solids) Other <br /> Grout Placeme Method I Pumped Free Fall Other -: Retardant/Accelerator(name) <br /> PEDESTAL Installed By n Driller Pump Contractor - Other <br /> Concrete Pedestal-2Dimensions:Width ft Length ft Thick <br /> in _ Christy Box 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 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 /> NIIN %It Nt Z4 1IOL k,%D! %.*N(ENO I I('E I*QLIRED hY)k INSI'L( I IONS-I'LLA.S1.( iLl.(209)95t-7h97 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date D? Area Employee ID# <br /> Grout Inspection By v c Date b/g f uz-L F SPECIAL Well Permit <br /> Pump Inspection By Date L WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS n <br /> PE SC Received Check#/ Amount Date Permit! Invoice# Well ID# <br /> codes Info Remi d Se ice Request# <br /> 2 Z <br /> 41.5�f l <br /> ERM3.06 IOM/2021 Pap I oft Wcll!Pump Pamrt <br />