AP2501708 - Laserfiche WebLink

Home Browse Search

l WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1863 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 NON-REFUNDABLE PERMIT CALL 209' 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED C(� Q �j .I qC, z i y JOB ADDRESS 1 7 7 �(J law I-f(ee rJ CITY/ZIP eS, l[, on l l '/� m j o D CROSS STREET S n le, APN 1/(� I J PARCEL SIZE ?,965 LAND USE J/APPLLIC APPLICATION # ��/f OWNER NAME Or(�(��y(�C m i ,;�/,_,,V�,I e6 PHO-NEE/1�7r1,!/) &K1--f 7y�`j 'OWNER ADDRESS 1 J rJ'/!22 Kt7�,/�(`i f fee, rd• CITY/STATE/ZIP /�/j.JQ 7 CONTRACTOR � ` (h 1 [n ��P��H��O��N``E ( ,t a9) /V'� D—1�7 CONTRACTOR ADDRESS ( CITY/STATE/ZIP ymct r /,63 1v 1(k SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER 1 r�-/CjL� EXPIRATION DATE DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) INTENDED USE ❑ Domestic/Private XIrrigation/Agricultural ❑ Industrial 0 Water Quality Monitoring ❑ Soil Sampling/Characterization ❑ Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK .New Well ❑ Replacement Well ❑ Well Alteration/Modification 0 Other Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair AgyM I New Pump ❑ PumpReplacement ❑ PumpRepair ❑ Raise Well CasingA T WELL CONSTRUCTION /�'� Drilling Method Mud Rotary ❑ Air Rotary 0 Auger Cable Tool ❑ Push Point 0 Other �r Proposed Well Depth 300 _ft .,Excavation It)" in diameter )(.Open Bottom 0 Gravel Pack/Gravel Size ICU ip?dert r Conductor Casing in diameter / Conductc Casing Depth � ft A. o Well Casing Diameter 1 in Thickness/Gauge/ASTM Sched e 1 d Steel 0 Plastic ❑ Stainless Steel ❑A +gIVAQV/N Grout Seal Depth ft 0 Neat Cement(94/b bag/5-10 gal water) ❑ Sand Cement KDentonite(20%solids) ❑ Other ., Grout Placement Method Xpumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) PEDESTAL Installed By yQDriller Pump Contractor ❑ Other 0 Concrete Pedestal❑Dimensions:Width:15_ft Length ft Thick a rt �in 0 Christy Box 7 Stove Pipe PUMP X,5ubmersibleo Turbine ❑ Other HP_k_o Pump Set ft Standing Water Level ft Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the following items: GPS Coordinates, property lines, adjoining properties, water bodies or courses, drainage pattern, roads, existing wells, structures, potential sources of contamination, sewers or private disposal systems. Include distance from two property lines. For Domestic, Agriculture,Industrial well,provide location of any water wells or surface water within 200'radius of proposed well. 3 24 HOE R ADVANCE NOT1"F PFOUIRED I'OR INSPECTIONS-I I EASE CALL I21t9)"53-76117 DEPARTMENT USE ONLY ✓ '`' Application Accepted By ZZ�I �Date Area Employee ID# Grout Inspection By Date 2 u SPECIAL Well Permit i Pump Inspection By Date 0 WAIVER Received Soil Boring Inspection By Date Co strutted Well Depth ft COMMENTS %� `I17 PE SC Received Check#1 Amount Date Permit/ Invoice# Well ID# Codes Info Cash, Remitted Service Request# / �,w Z 2� 2s I�P25ml�g L.HD043-06 09/07/2022 n^ - �/] Page I oft Well/Rump Permit