Laserfiche WebLink
z7n1!t <br /> D <br /> WELL/PUMP PERMIT G,�,j <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT A, CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1Y�EAR FROM DATE ISSUED <br /> JOB ADDRESS J� CnYZI <br /> IV _ MrU CVjYYI ���� mN <br /> f/�r 1 P-7rJ <br /> CROSS STREET / I / APN I V ~�1 PARCEL SIZE / LAND USE APPLICATION# O <br /> (\� M <br /> OWNER NAME ( ' 1 IJ I' I PHONE (Inr` , <br /> OWNER ADDRESS CrTYISTATE/ZIP � <br /> !CONTRACTOR mm-U6 1) IAIU ('\ PHONE ,/_` 17_0 <br /> N10c(.� fi� G L q'1 >_3�77 <br /> CONTRACTOR ADDRESS I I l/ 'J rnYISTATEJZIP r i <br /> SUBCONTRACTOR LV PHONE <br /> SUBCONTRACTOR ADDRESS CrTY1/SSTATE/ZIP r— <br /> LICENSE 57 E C-61 EX D-09 Other NUMBER V EXPIRATION DATE <br /> C <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) Y <br /> 'INTENDED USE DomesticlPrivate IrrigationiAgricuttural I: Industrial C Water Quality Monitoring ': Soil Sampling/Characterization 'V <br /> ublic Water System O <br /> It ddfe en;from Owrer Water System Name Contact Name or Phone Number JUN <br /> TYPE OF WORK New Well replacement Well Well Alteration/Modification E Other_ q <br /> _ Monitoring Wells) #of wells Soil Boring(s) u of nonng5 Geotechnical /N <br /> Out-Of-Service Well ^ Out-Of-Service Well Renewal Cross-Connection Repair NTH pFpgF/C0� ;, <br /> _ New Pump Pump Replacement Pump Repair Raise Well CasingR <br /> WELL CONSTRUCTION T <br /> Drilling Method `�Mud Ro Air Rotary LI Auge Cable Tool Push Point Other <br /> Proposed Well bepth�ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conduc Casing Depth ft <br /> Well Casing Diameter in Thickness/Gau ed ge/ASTM Sch , Steel Plastic Stainless Steel Other <br /> Grout Seal D.epth�� ft ' Neat Cement(941b bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) %I Other <br /> Grout Placemen�ethod Pumped Free Fall ; Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By _ Driller Pump Contractor Other <br /> Concrete Pedestal -Dimensions:Width ft Length ft Thick <br /> jin _ Christy Box - Stove Pipe <br /> �PuMP SubmersibleC•Turbine _ Other HP Pump Set ft Standing Water Level <br /> Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the following items: GPS <br /> Coordinates, properh lines, adjoining; properties, water bodies or courses, drainage pattern, roads, existing Hells, structures, <br /> potential sources of contamination, sewers or private disposal sNstems. 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 /> !Ol! i)R I L.4sf.L'ALL. <br /> DEPARTMENT USE ONLY <br /> I 1 <br /> Application Accepted By y Date 'La tk Area j I�'� Employee ID# Jks <br /> Grout Inspection By ate L J.�2 ` C SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date -� Constructed Well Depth i ft <br /> COMMENTS INS v`�t� \l r��L {.fiLDv� ���n� Fit e r `�N �-1 v t ��.1 -O�}�� t' F L zX� <br /> it YL L �h ✓V' Lr1. t-CJ L We 5 ,0_, e 'J L1 <br /> PE SC Received Check#/ Amount fU Perm <br /> Codes Info B Cash Remitted Date Service Re uest Invoice# Well IOax <br /> wl� Vj � a <br /> • J <br /> 28& N2, <br /> t tiD013-06 OL07R022 I�3�7 Ya L�age I of 2 W fI B� U Will!Tamp Poma <br />