Laserfiche WebLink
E AILED <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 A} CALL 209 953-7697 FOR INSPECTIONS EXPI�I,RESn1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS I V 1 CQ O'V 1 CrrY/ZIP l)I V -I �✓ �Y in <br /> Ir <br /> CROSS STREET r rO' APN 'J I�O ,PARCEL SIZE d —13 LAND USE APPLICATION <br /> OWNER NAME V PHONE -M �"1�{,'� in <br /> !OWNER ADDRESS I �V CITY/STATE/ZIPlI/��J <br /> CONTRACTOR �b//�JJj I low� iN J' PHONE 2,10q (i�7_ 1"I� <br /> �CONTRACTOR ADDRESS "l f 1 I V V�'S f 'y CITYISTATE/ZIP VW C/O) 1 q_��7 1 <br /> !SUBCONTRACTOR PHONE <br /> I <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C-57 _ C-61 D-09 Other NUMBER EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING:-xGeneral Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private L Irrigation/Agricultural -_ Industrial _ Water Quality Monitoring -: Soil Sampling/Characteri <br /> Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK 17 t4ew Well Replacement Well ❑ Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells ❑ Soil Boring(s) u of borings Geotechnical " <br /> Out-Of-Service Well ❑ Out-Of-Service Well Renewal _ Cross-Connection Repair �Q <br /> New Pump Pump Replacement ❑ Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION �TyO PMF,y�•UN <br /> Drilling Method*ud Rotacy Air Rotary Auger L Cable Tool _ Push Point Other <br /> Proposed Well uepth �j_ft Excavation A in diameter Open Bottom _ Gravel Pack/Gravel Size in d <br /> C Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter In Thickness/Gauge/ASTM Sched"i C Steel Plastic 7 Stainless Steel Other <br /> Grout Seal Depth � It Neat Cement(94 lb bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) J Other <br /> Grout Placement Method 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 /> in Christy Box G Stove Pipe <br /> PUMP 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 ",yell siith respect to the folloiNing items: GPS <br /> Coordinates, propert}' lines, adjoining properties, «ater bodies or courses, drainage pattern, roads, existing wells, structures, <br /> potential sources of contamination, sewers or private disposal systems. Include distance from two propertNI lines. For Domestic, <br /> Agriculture,Industrial well,provide location of any water Nvells or surface is ater within 200' radius of proposed is-ell. <br /> \Ii.Al.\il 1l 24 IIOL R ALA AACE NOTICE RLQL Iki:U I-OR I\1PE( HUMS-PLEASE CALL(209) <br /> DEPARTMENT USE ONLY <br /> Application Accepted By /f 5fr�iv Date tC—ZZ—2,0Z,5_ Area Employee ID# e---� <br /> Grout Inspection By / y Date 1,U12�17_S ❑ SPECIAL Well Permit <br /> Pump Inspection By Date C. WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS OJel t'b Ae- 106 <br /> PE SC' Received Check#/ Amount Date Permitl Invoice# Well ID# <br /> Codes Info B Cash Remitted ervice Request# <br /> EHD073-066410712022 , �I0s6-g3g�P letz Uploaded into Accela"' p <br />