WP0042863 - Laserfiche WebLink

Home Browse Search

:ss3aaav niS N7. 1 WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDABLE PERMIT CALL (209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS ‘i CL"? k(.0 C4 CITY/ZIP CROSS STREET Cia(Vikk N \ kaA) W APN 340 — 00 R-3 PARCEL SIZE t,.::4) 6 P (LAND USE APPLICATION # OWNER NAME cl-U.0 110 C-0 WO ?-er-k9 n f, -I-v(4cl T LA PHONE P/A r. OWNER ADDRESS 3 -6 G141,4) /.1.41 C-(1 Dry/STATE/Zip Ptyctsayrial /CA / (0 SkiD rt —lirk9 PHONE (206i )110 - 1 -/a) CONTRACTOR \I t U.) p '1 I ' CONTRACTOR ADDRESS. k 7) -2.3 9,4A-L 4qUiryi- .VI" • cirdsTATE/Lp --tki / CA- / (131'3 L' SUBCONTRACTOR kitt Alqt,be — -W,-, a. PM6uu1o PHONE 10 41 I, — 14'L( 1 r s :17_ , r SUBCONTRACTOR ADDRESS ;`)J ,.."-) 11/16...(A.Ay( a (. V-)l &a - cirdsTATEIzip u,I•e.J1 YkcfrtAtv4144-0 I CA- 16113-ji I LICENSE 1C-57 0 C-61 0 D-09 0 Other NUMBER 1 2.()CIOL4 EXPIRATION DATE 416A) I 20 2R. DOMESTIC WELL SAMPLING: 0 General Mineral/Coliform Bacteria (4391) 0 Dibromochloropropane (4392) 0 Arsenic (4393) INTENDED USE 0 Domestic/Private 0 Irrigation/Agricultural 0 Industrial 0 Water Quality Monitoring ErS-oil Sampling/Characterization 0 Public Water System If different from Owner Water System Name Contact Name or Phone Number TYPE OF WORK 0 New Well 0 Replacement Well 0 Well Alteration/Modification 0 Other 0 Monitoring Well(s) # of wells 0 Soil Boring(s) # of borings get'eotechnical 1 # of borings 0 Out-Of-Service Well 0 Out-Of-Service Well Renewal 0 Cross-Connection Repair 0 New Pump 0 Pump Replacement 0 Pump Repair 0 Raise Well Casing PA WELL CONSTRUCTION C010 Drilling Method 0 Mud Rotary 0 Air Rotary VAuger 0 Cable Tool 0 Push Point 0 Other Proposed Well Depth l S -3O ft Excavation in diameter 0 Open Bottom 0 Gravel Pack/Gravel Size Opeir8ter 0 Conductor Casing in diameter / Conductor Casing Depth ft 4 a SAN J Well Casing Diameter in Thickness/Gauge/ASTM Sched 0 Steel 0 Plastic 0 Stainless Steel 0 Other A Grout Seal Depth k .5; - .gC) ft 0 Neat Cement (94 lb bag/5-10 gal water) 0 Sand Cement Yak CNA 0 Bentonite (20% solids) 0 Other .D P tit ,, - er l(LittnIfire _____AR , c,,,, 0.x,,,,v N Grout Placement Method 0 Pumped DrFree Fall 4 Other :1-r€.3m t 4- .,- 4/1111 -eiardant / Accelerator (name) ri PEDESTAL Installed By 0 Driller 0 Pump Contractor 0 Other 0 Concrete Pedestal 0 Dimensions: Width ft Length ft Thick in 0 Christy Box 0 Stove Pipe PUMP 0 Submersible0 Turbine 0 Other HP 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. MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 DEPARTMENT USE ONLY 12/22/2/ 5/7-Ch Cy' A Application Accepted By Date Area Employee ID# Grout Inspection By A. --- Date %U 22. 0 SPECIAL Well Permit Pump Inspection By Date 0 WAIVER Received Soil Boring Inspe.ction By Date Constructed Well Depth ft COMMENTS nOCk re543 a S I'? 5Gti I 2-4 -/- 10. Vo,Awro. (U.— PE Codes SC Info Received d_her.k#4.1 Cash Amount Remitted Permit/ Invoice # Well ID# 437a is-0 60- 522_324 fl.3R. 2 Ft.ii i s Servige Resipst #:3 Lt..1)001F -`6(1 EHD043-06 10/25/2021 Page 1 of 2 Well / Pump Permit