Laserfiche WebLink
1. . , . ells � � <br /> WELL/PUMP PERMIT <br /> SA.,1 JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS /EXP_IIRES�1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS /1256 Al &16 k'r Z&"z L CITY/ZIP (��{/ 4I� �/�t y� m <br /> /r/0� � Qp + CC - �/�y D <br /> CROSS STREET y� LAPN oJ� /�-D�/ PARCEL SIZE S LAND USE APPLICATION# Q <br /> OWNER NAME it 1 �L4( 2 PHONE ?Q% 7 � �3 / �+ <br /> 'I I/ /C <br /> OWNER ADDRESS `-) �7Z �Ca¢ �tr'L 1c �' CITY/STATE/ZIP LPU/ Lt� C�J7JiY0 <br /> CONTRACTOR p`3 ✓� r G��t I (� PHONE `0/ 77 7i' 2 Z S 7 <br /> CONTRACTOR ADDRESS 4/1" 561"116"e/j///7 �� CITY/STATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE -57 C-61 D-09 Other NUMBER 101 71)70 EXPIRATION DATE �' 3� zel Z <br /> 12� <br /> DOMESTIC WELL SAMPLING:�General Mineral/Coliform Bacteria (4391))(Dibromochloropropane (4392)k Arsenic(4393) <br /> INTENDED USE XDomestic/Private Irrigation/Agricultural Industrial 1 Water Quality Monitoring Soil Sampling/Chara yZation <br /> Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Num ECE, 9 <br /> TYPE OF WORK )(New Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells Soil Boring(s) #of borings Geotechnical JUL#2 bphn.T,` <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair SAN j ��(' 1 <br /> New Pum Pum Replacement Pum Repair Raise Well CasingENIE VOAQII/N COU <br /> WELL CONSTRUCTION iLuiLTH DEPARTAL <br /> Drilling Method Y Mud Rotary Air Rotary Auger Cable Tool Push Point Other MEN, <br /> Proposed Well Depth 3760 ft Excavation in diameter Open Bottom 'Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter- in Thickness/Gauge/ASTM Sched Q 2/ Steel XPlastic Stainless Steel Other <br /> Grout Seal Depth 2.40 ft Neat Cement(94 Ib bag/5-10 gal water) Sand Cement /6 sack mix/7 gal water <br /> Bentonite(20%solids) 1 Other —� <br /> Grout Placement Method umped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed ByDriller Pump Contractor Other <br /> Concrete Pestal Dimensions:Width ft Length ft Thick <br /> in Christy Box Stove Pipe <br /> PUMP }(Submersible Turbine Other HP Pump Set U ft Standing Water Level <br /> Plot Plan Ren Ren quirements: Attach a plot plan with the exact location of water well with respect to the following items: GPS <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 /> \IININIL�NI 24 1IOLIR ADN AN(L NO I('E: Rh:Qt IRE:D FOR INSI ECA IONS-PLEASE:('11.L(2U9)9;;3-7697 <br /> 11 DEPARTMENT USE ONLY v GG <br /> Application Accepted By l� z �i Date -7/.?) ;?a Area 1 Employee ID# Fctink <br /> Grout Inspection By Date ✓L ❑ SPECIAL Well Permit <br /> Pump Inspection By E F'-' Date L Z ❑ WAIVER Received <br /> Soil Boring Inspection By JDate Constructed Well Depth ft <br /> COMMENTS well G( y NC( it C/ l2w'e 1-J01er <br /> -�S, '� � -�z 1. I(, <br /> PE SC Received Chec Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By_ Remitted Service Request# <br /> . Cri <br /> 4366 )$b %tb <br /> ws4 ) �1 SS <br /> 43ya 76 <br /> 43.93 Va <br /> EHD043-06 10/25/2021 Page I ol'2 well/Pump Pe"I'a <br />