Laserfiche WebLink
DocuS�n Envelope ID:CBF5FEBB-471A-4724-B90A-2589A1E26D00 <br /> 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 �'(EEX^PIIR�E/�S�1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS L I CITY/ZIP I Y t V" !C 01 30 m <br /> CROSS STREET E7` r �C�`d� r, �/{ 0 <br /> APN I� u -� PARCEL SIZE 1 1 LAND USE APPLICATION# v <br /> OWNER NAME �n1 CA, 11�1 �v y�yv�QV �Z� PHONE ZX <br /> M <br /> OWNER ADDRESS v 64, V( J CITY/STATE/ZIP <br /> CONTRACTOR PHONE OLe` •ol 04 <br /> CONTRACTOR ADDRESS Q1��'-C�C f9 CITY/STATE/ZIP �A A/) �' <br /> SUBCONTRACTOR N 4" PHONE <br /> SUBCONTRACTOR ADDRESS CATTY//ST�A.TE/ZIPn <br /> LICENSE C-57 ❑ C-61 11D-09 ❑ Other NUMBER\( t"1 , llt EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING: ;X General Mineral/Coliform Bacteria(4391) Dibromochloropropane (4392) Arsenic(4393) <br /> INTENDED USE )I Domestic/Private ❑ Irrigation/Agricultural Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> ❑ Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK XNew Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other PA ve <br /> Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical � "a <br /> ❑ ❑ /�N�' <br /> Out-Of-Service Well ❑ Out-Of-Service Well Renewal Cross-Connection Repair ,1 c e6 <br /> ❑ New PumpPumpReplacement ❑ PumpRepair ❑ Raise Well CasingAP <br /> WELL CONSTRUCTION 2 <br /> Drilling MethodX Mud Rotary Ci Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other S��OgQ 0 7 <br /> Proposed Well Depth_ 121 J2D ft Excavation _ in diameter ❑ Open Bottom '7,,Gravel Pack/Gravel Tyr /djgrpter <br /> Aj <br /> 11 Conduct Casing in diameter / Conductor Casing Depth ft qRT <br /> Well Casing Diameter in Thickness/Gauge/ASTM SchedQdl. ❑ Steel W Plastic ❑ Stainless Steel ❑ Other MENT <br /> Grout Seal Depth ft ❑ Neat Cement(94/b bag/5-10 gal water) ❑ Sand Cement sack mix17 gal water <br /> -V Bentonite(20%solids) ❑ Other <br /> Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal ❑Dimensions:Width ft Length ft Thick <br /> in ❑ Christy Box D 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 /> MINI\It'11 24 110('R AD%,X's( F 1t)1'I(:(i IZI.1O('II7EU 1"011 IV'tiPfC`(IONS-I'(1;ASI?{'aL.L,(2119)9ii-769? <br /> DEPARTMENT U E 9NLY <br /> Application Accepted BY PP P Date `T Area S/9 9 Employee ID# <br /> A <br /> Grout Inspection By Date 11 SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS rr II I It a 11 Ir r1 r�(► II I I II <br /> awl 11Z, >e'lc�rrrut4&1. <br /> PE Sc Received CCheck-#N Amount Permit) <br /> Codes Info B as Date Remitted Service Request# Invoice# Well ID# <br /> 6-'t ba, 2ZO X"/*Zv 4-22-24 HP0045453 <br /> EHD043-06 04/07/2022 Page I of 2 Well!Pump Permit <br />