WP0044266 - Laserfiche WebLink

Home Browse Search

EMAILED 1 WELLIPUMP PERMIT SAN JoAQLm CouNTY EwvworwrxTAL HEALTH DV ARTIENT 1868 EAST HAzELTON AvEwUE-STOCItTON CA 95205 -(209)4W-UM NON-REFUNDABLE PERMIT �y1CALL 209 953-7597 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED Jos ADDRESS CmIZIF' CROSS STREET 1 APN l�y l^1 UU O�SI PARCCL SIE �/�ffi-(Z ILAND USE INA #�1Ci�w L� 1 A OWNER NAME L PHONE WA V "I - - 15 V FF�� OWNER ADDRESS CITYISTATElZIP CONTRACTOR �/'��G� �— }P1HONEE CONTRACTOR ADDRESS 1 1 ��l CITYIS�ATEIZp �l/IrR�1V C 'y,� SU6CONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITYISTAJTTEIZIP LJCt31aE C-67 ❑C-61 ❑ D-09 ❑ Other NumslER lyFXPIRATION DATE DOMESM WEta ;[I General Miner-al/CdifOrm Bacteria(4391)G Dibrnrnochbropbpane(4392)❑ Arsenic(4393) NOMMtM Domes6dPrivate ❑ krVabordAGriculhxal ❑ Industriat 0 Water Quality Monitoring ❑ Soil Sampling/Characterization ❑PL"c wafer System it d1forwo from Owner wait Syown Name cotters Name«Phone Nortel TYPE OF WORK New well ❑ Replacement well ❑ Well Alteration/Modification ❑ Other ❑ Monitoring Well(s). #ar walla ❑ sol Boring(s) aK of b"vs ❑ GeoteCIIMCOI K of borings ❑OUt-Of-Service Well ❑ Out-ofService Well Renewal ❑Cross-Connecbon Repair ❑ New PLwnp ❑ Pump Repkicament ❑ Pump Repair ❑ Raise Wei CaS1 . a Drhltkv Method Mud� Y ❑ Air Rotary ❑Auger ❑ Cable Tod ❑ Push Point ❑ Other Proposed yy� pith�1U1]' tt Excavation ._in diameter ❑ Open Bottom Gravel Padc/Gravel Size in diameter ❑ —Casing— in diameter i Conductor Casing Depth ft Well Casing Diameter in TMdmesslGa�ASTM Schad- [] Steel ❑ Plastic ❑ Stainless Steel LlOther Grout Seal I ft [I Nee Cemerd(941b bbag✓5-10 gat WSW [u Sand Cem nt sack rnrx/7 gal water 20%solids) ❑Ostler Grout PlarrsnNnt sthod Pumped ❑ Free Fau ❑ Other ❑ Retardant/Accelerator(name) — !'�4 installed By ❑ Drbw ❑ Pump Contractor ❑ Other_ p,4yllA�",�— ❑ Concrete Pedestal❑Dir>srwions:Width ft Length ft Thick REr%fts in ❑ Clwisty Box ❑ Stow PIQs EM D Subroers"e❑Turbine ❑Other HP Pump Set ft StarRdi ft Plot Plan Regairemeats: Attach a pit plan with the exact location of water well with respect to ties,(q%T gjVps: GPS Coordinates, property lines, adjoin properties,water bodies or coarses, drainage patters, roads, exWctures, potential sources of contamination,hewers or private disposal systems. Include distance from two property lines. or Domestic, Agriculture,Industrial well,provide location of any water wells or surface water withtn 2041 radius of proposed well. MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)'57^7697 �c�r� DE ARTMENT US O Y Applications'.ey �� Area 9 / Employee ID# ' Grout Inspersion By — Date 0 SPECIAL Well Permit Pump Inspection By Date 0 WAIVER ReCelved Sdi Bortng Inspection By Date Construclied Well Depth ft COMMENTS PE SC CltaClsfl Amount Dees perm N Invoice/ Well IDR Codas Info Rsmltbd Service Requedalt 9 aD yqZ(o 6P tHID0I3U604Wt2z2 � � �� / i f / b� ��otz � w.ni P-m: