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4200/4300 - Liquid Waste/Water Well Permits
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WP0037376
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Last modified
6/27/2018 2:05:30 PM
Creation date
5/23/2018 2:13:59 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
WP0037376
PE
4381
FACILITY_NAME
MARIA NAVARRO
STREET_NUMBER
10325
Direction
S
STREET_NAME
CROCKER
STREET_TYPE
RD
City
STOCKTON
Zip
95206
APN
19103001
ENTERED_DATE
5/23/2018
SITE_LOCATION
10325 S CROCKER RD
RECEIVED_DATE
10/4/2017
P_LOCATION
99
P_DISTRICT
003
Tags
EHD - Public
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14874 WELL/PUMP PERMIT <br />SAN .JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue - STOCKTON CA 95205.6232 - (209) 468.3420 <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />.los ADDRESS 10325 CROCKER RD. ClnlzlP STOCKTON 95206 <br />CROSS STREET HOWARD APN 1 91-03-001 PA CEI S/tE 6 2 . 9 4AIVD USE APPLICATION # <br />OWNER NAME MARIA VAVAR RO PHONE 6 8 4 -112 3 <br />OWNER ADDRESS SAME CITY%STATE/ZIP <br />CONTRACTOR Delta Pump 4TC)rVTQN ARMATURF' r MOTORWORKS tom_ 2(]A—zrr;_Oti,)S <br />CONTRACTOR ADDREss 646 S. California Street <br />ITYISIATE21P StOCI&L011, UPI y)/U3 <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS CISYIST AiE1Z1P <br />LICENSE C] u C-57 K C-61 D D-09 0 Other NUMBER 724778 EXPIRATION DATE_08IIq, <br />GEOGRAPHICAL INFORMATION: Coordinates X Y <br />Township Range Section <br />INTENDED Ep USE�Domestic/Private 0 Irrigation/Agricultural 0 Industrial 0 Water Quality Monitoring 0 Soil Sampling/Characterization <br />0 Public Water System <br />If different from Owner: a er ys em ame <br />on a ame or one um r <br />TYPE OF WORK 0 New Well 0 Replacement Well 0 Well AlteratiONModification 0 Other <br />0 Monitoring Wells) # of wells 0 SOII Boring(s) # of borings # of borings <br />C Out -Of -Service Well -, a Geotechnical <br />Out -Of -Service Well Renewal 0 Cross -Connection Repair <br />0 New Pum X Pum Re <br />WELL CONSTRUCTION lacement 0 Pump Repair 0 Raise Well Casing <br />Drilling Method C Mud Rotary :j Air Rotary 0 Auger 0 Cable Tool 0 Push Point 0 Other <br />Proposed Well Depth it Excavation in diameter 0 Open Bottom 0 Gravel Pack/Gravel Size in diameter <br />0 Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched <br />Grout Seat Depth 0 Steel 0 Plastic 0 Stainless Steel 0 Other <br />P ft C Neat Cement (941b bag/5-10 gal water) 0 Sand Cement <br />Bentonite (20% solids) D Other sack mix/7 gal water <br />Grout Placement Method 0 Pumped 0 Free Fall Other <br />0 Retardant /Accelerator (name) <br />PEDESTAL Installed By DO Driller 0 Pump Contractor 0 Other <br />Concrete Pedestal Dimensions: Widthin 0 Christy Box 0 Stove Pipe ft Len th <br />g h Thick <br />PUMP Submersible0 Turbine 0 Other__ <br />HP 0.5 Pump Set_ 3 7 ft Standing Water Level 7 .5 ft <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WIT CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATIO AWS. <br />�� •6 1 . t <br />VA CE NOTICE REQUIRED INSPECTIONS <br />FORis // <br />oil TITLE CEO <br />DATE <br />F1 NEW T4 0 ljjjjfjj�� <br />NOTE: DID NOT HAVE THE LOCATION OF THE PUMP/WELL <br />ON THE PROPERTY UNTIL THE JOB WAS COMPLETED. <br />Louise Fornos <br />Office Manager <br />DEPARTMENT USE ONLY <br />Application Accepted By <br />Grout Inspection By Date <br />Pump inspection By Date <br />Soil Boring Inspection By Date <br />COMMENTS :� r. ,_. 11 Date <br />/ n <br />EHD 43.06 <br />8104/08 <br />u <br />AToa G (I <br />Employee 1D# p, <br />SPECIAL Well PermitYET <br />WAIVER Received n c�/V�® <br />Constructed Well DAnth <br />C� b 201? <br />WELL /PUMP PERMIT <br />a <br />
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