Laserfiche WebLink
1 WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 96206 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL 209 963-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DAT I <br />ADDRESS <br />CROSS STREET_ <br />OWNER NAME <br />OWNER ADDRESS <br />CONTRACTOR <br />� � � E SSUED <br />J CITY/ZIP �5-33 7 <br />Q Y'1 Y1 <br />APN �� <br />DU -0-2— PARCEL S <br />IZED, LAND USE APPLICATION #+ <br />.P q,�� <br />PHONE O <br />CONTRACTOR ADDRESS _ SO nr 41 C ook f) -c- %1 <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE ❑ C-57 VC -b1 ❑ D_09 ❑ Other <br />DOMESTIC WELL <br />INTENDED USE <br />CITY/STATE/ZIP <br />/''��Q PHONE _209 -591 -3t/5 -e. <br />V/S <br />CITTATE/ZIP LJ�L� e 9- g 5- _ 7 i I <br />PHONE <br />CITY/STATE/ZIP <br />NUMBER 1052Lf757' EXPIRATION DATE 4-3 V" e, -7--Zj <br />LING: ❑ General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) ❑ Arsenic (4393) <br />ioctir/D,-, - <br />- - - -youvnrnynuunurai u Industrial ❑ Water Quality Monitoring ❑ Soil Samplin <br />❑ Public Water System gJCharaeterization <br />If different from o.., <br />TYPE OF WORK ❑ New Well ❑ Replacement Well <br />❑ Monitoring Wells) # of wells <br />❑ Out -Of -Service Wel <br />❑ New Pump LePump Replacement <br />WELL CON.11 m Ir•Tln. <br />System Name <br />11Well Alteration/Modification <br />❑ Soil Boring(s) <br />11 Out -Of -Service Well Renewa <br />Contact Name or Nhone Number <br />❑ Other <br /># or borings ❑ Geotechnical <br />I ❑ Cross -Connection Repair <br />❑ Raise Well Casino <br /># of bonngs <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter 11 Open Bottom ❑Gravel Pack/Gravel Y11I1 <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft 9 in diameter <br />Well Casing Diameter_ in Thickness/Gauge/ASTM Sched REQ <br />Grout Seal Depth ❑Steel ❑Plastic ❑Stainless Steel ❑ t r <br />p ft ❑ Neat Cement (94 lb bagf5-10 gal water) ❑ Sand Cement j , <br />❑ Bentonite (20% solids) ❑ Other ��� ac rx gal water <br />Grout Placement Method ❑ Pumped ❑Free Fall U Other -- - ourtty <br />❑Retardant /Accelerator (name) ^°' ,uoNrne <br />I'EDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other _ <br />❑ Concrete Pedestal ❑Dimensions: Width ft Length ft Th <br />In ❑ Chr� Box ❑ Stove Pioc --_- <br />cyouDmerslble❑ Turbine ❑Other1 <br />HP Q Pump Set ft Standing Water Level _ ft <br />Plot Plan Requirements: Attach a plot plan 'l the exact location of water well with respect tc the follo;ti;.ig Items: GTj <br />Coordinates, property limes, adjcirting pope ties, 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 Iocation of any water wells or sof fate ;,atei ji ithii- 2-30' 1 adios „f propos; <br />liNllflal;3l 2=1HOUR 1IDV:AN(E ? Q3'?CE ! F0 T71 VT) r.01 7 fifl'T 4'? iS?'iS - PLEASE L CALL (209) S3', -769i <br />DEPARTMENT USE ONLY f�� <br />Application Accepted By Date L �7i Area _?" (- v/ Employee ID# <br />7_ <br />Grout Inspection By Date ❑ SPECIAI- Well Perlt3il <br />Pump Inspection By _ Date i �{ T� I�� lr Z p Z- <br />Soil Boring Inspection By Date <br />COMMENTS <br />--- <br />Info <br />9D <br />Amount I Date <br />Remitted <br />E4 <br />Constructed Well Depth ft <br />Permit/ <br />Service Request # Invoice # <br />Well ID# <br />F14D04-1-06 to/ I 1 L/ U,S� l 3 l�% / / ��Page 1 ort I --- <br />/ I (/ Wcll I Pump Pcruut <br />T <br />m <br />D <br />a <br />O <br />m <br />y <br />N <br />