Laserfiche WebLink
EMAILED <br /> 1 WELL/PUMP PERMIT <br /> SAN 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 EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESSman {//�� h'/�' CITYI p f I '�t C-W m <br /> CROSS STREET ���APN 22� � /V- O' O PARCEL SIZE L�1 LAND USE APPLICATION# p <br /> OWNER NAME Jrw I PHONE <br /> ,/� <br /> OWNER ADDRESS CITY/STATEIZIP �vnf 7 <br /> CONTRACTOR I 1 1 U PHONE -r)22 I 1- v�j <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP U C q Co% 7 <br /> SUBCONTRACTOR l nnt, <br /> Y PHONE <br /> SUBCONTRACTOR ADDRESS CrTY/STATE/ZIP <br /> LICENSE C-57 _ C-61 D-09 Other NUMBER EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING:XGeneral Mineral/Coliform Bacteria(4391)-4Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private Irrigation/Agricultural ] Industrial ❑ Water Quality Monitoring 7. Soil Sampling/Characterization ' ^ <br /> Public Water System <br /> If different from Owner. Water System Name Contact Name or Phone Number T <br /> TYPE OF WORK a New WellReplacement Well Well Alteration/Modification C Other VFW <br /> ❑ Monitoring Well(s) #of wells Soil Boring(s) #of bOOngs Geotechnical #of bonn*A/ <br /> ❑ Out-Of-Service Well _ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> /YY <br /> New Pumpi' PumpReplacement :1 Pump Repair Cl Raise Well Casingp S4N JO o�4 <br /> VIR <br /> WELL CONSTRUCTION Air Rotary Auger Cable Tool Push Point Other NEA`rh DS6 A <br /> Drilling Method Mud L T y Rota <br /> Proposed Well epth _ft Excavation II in diameter Open Bottom Gravel Pack/Gravel Siz in diameter ENT <br /> Conduct r Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter In Thickness/Gauge/ASTM Sched'7-00 Steel Plastic Stainless Steel _ Other <br /> Grout Seal Depth ft G Neat Cement(94lb bagi5-10 gal water) Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) ❑ Other <br /> Grout Placement Method Pumped "I Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By _ Driller -1 Pump Contractor .._ Other <br /> Concrete Pedestal LiDimensions:Width ft Length ft Thick <br /> in Christy Box Stove Pipe <br /> PUMP Submersible— Turbine 'I 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: 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 /> MININIL it 24 IIOLR AUb AN(E NOTICE REAL IREl)FOR INSPECTIONS-PLEASE CALL(209)953-707, <br /> DEPARTMENT USE O LY <br /> /� c V KL <br /> Application Accepted By�f Date lG> Area Employee ID# <br /> Grout Inspection By Date 7 SPECIAL Well Permit <br /> Pump Inspection By Date 1 1 WAIVER Received <br /> Soil Boring Inspection By Dale Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#I Amount Date PermiU Invoice# Well ID# <br /> Codes Info B Cash Remitted Service Request# <br /> 'f37� --C1L- Z�) t 2- 4 � <br /> . c%! /f 0 <br /> 3 JV - <br /> EHD043-0o 04'07.2022 ,'�_ Page I of 2 H'cll:Pump Pc'nut <br /> (L�t)'LLrtJtll' �t/' �L <br /> /Szg�Zb`fS` <br />