Laserfiche WebLink
1 WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 -(209)4683420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES////1 YEAR FROM�DATE ISSUED <br /> JOB ADDRESS ,U 4 r ` CrrylZIP NON. <br /> CROSS STREET <br /> II t a �( t�JAPN z� 310 PARCEL SIZEI 'LAND USE <br /> E AX1PP8LIC8ATI1O�N 2�# <br /> �� <br /> !MOWNER NAME GN 0 PHONE <br /> 'OWNER ADDRESS -)-0 O 11 111-D sto^l\ H CITYISTATE/ZIPF12M . � �N <br /> CONTRACTOR f C16 INC/ PHONNErZZ <br /> CONTRACTOR ADDRESS CrrY/STATE/ZIP Wan. np <br /> W els�57 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATEIZIP <br /> 1 <br /> LICENSE C-57 C-01 D-09 Other NUMBER ! EXPIRATION DATEVI <br /> DOMESTIC WELL SAMPLING:>oGeneral Mineral/Coliform Bacteria(4391)YDibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE )'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 New Well )f Replacement Well 0 Well Alteration/Modification ❑ Other �c• <br /> Monitoring Wells) #of wells ❑ Soil Boring(s) pOrbOeng, 11, Geotechnical 0otbor1' � <br /> �A�O, `O <br /> Out-Of-Service Well 0 Out-0Sf-Service Well Renewal Ll Cross-Connection Repair <br /> New Pump Pump Replacement 0 Pump Repair 0 Raise Well Casing qN J ?� <br /> WELL CONSTRUCTION FqG t//RO�/N C <br /> Drilling MethodMud Rota Air Rotary _ Auger Cable Tool 0 Push Point [IOther THD NM NTY <br /> Proposed Well epth ft Excavation �_ in diameter 0 Open Bottom '�Gravel Pack/Gravel Size* in iia <br /> Con ductcy Casing indiameter / Conductor Casing Depth ft NT <br /> Well Casing Diameter in Thickness/Gauge/ASTM SchedrFl Steel Plastic Stainless Steel Other <br /> Grout Seal Depth i ft E Neat Cement(941b bagl5-10 gat water) Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) -- Other <br /> Grout Placement Method Pumped C Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller := Pump Contractor Other <br /> Concrete Pedestal:.:Dimensions:Width ft Length ttThick <br /> in Christy Box Stove Pipe <br /> PUMP iJ 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: CIPS <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 /> 1iI\I>iL�i24HOLR.XDN \NCENOIICE. I(F:Qi.IitFa)FORI.NSPECTIONS-PLEASE('.41.1.(21Y))953-7697 <br /> DEPARTMENT U ENLY (� <br /> Application Accepted By Dale S 7 P� Area 7 Employee ID# <br /> Grout Inspection By Date S lIC"Z ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection 13y Date Constructed Well Depth ft <br /> COMMENTS Z r • <br /> PE SC Received Cheeky/ Amount PermW <br /> Codes Info sh emitted Date Serviu R Invoice/ Well ID# <br /> c <br /> EHM3,06 040720L' Pale I o1`2 WcII/Purtp Pemut <br />