Laserfiche WebLink
A ' I WELLIPUMP PERMIT <br />SAN A)AQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST IHAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />1114 4-1114-Mtt-UNUAl3Lt rt:KMIT <br />(` <br />jJOB ADDRESS 19500 W Bacon Island Road <br />(CROSS STREET Bacon Island <br />L;ALL (ZU9) 953-7697 FOR INSPECTIONS EXPIRES 9 YEAR FROM DATE ISSUED <br />OWNER NAME Metro Water District of Southern California <br />OWNER ADDRESS PO Bix 54153 <br />CONTRACTOR Exploration Geoservices, Inc <br />ADDRESS 563 Asbury Street <br />CfTY/ZIP Stockton, California <br />APN 129-05027 PARCEL SIZE I ( LAND USE APPLICATION # <br />PHONE <br />CITY/STATE/ZIP Los Angeles. California 90054 <br />PHONE 408-280-6822 <br />CITY/STATE/ZIP San Jose, California 95110 <br />SUBCONTRACTOR Hultgren - Tillis Engineers PHONE 925-685-6300 <br />SUBCONTRACTOR ADDRESS 4085 Nelson Avenue, Suite A CITY/STATE/ZIP Concord. California 94520 <br />LICENSE 0' C-57 C-61 D-09 Other NUMBER 484288 EXPIRATION DATE 1213l/2023 <br />DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) ❑ Arsenic (4393) <br />INTENDED USE (I Domestic/Private Irrigation/Agricultural . Industrial Water Quality Monitoring 0 Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Owner Water System Name Contact Name or Phone Number <br />TYPE OF WORK ❑ New Well Replacement Well ❑ Well Alteration/Modification Other <br />Monitoring Well(s) # of wells ❑ Soil Boring(s) u of borings ElGeotechnical <br />Out -Of -Service Well a Out -Of -Service Well Renewal - Cross -Connection Repair <br />New rump <br />- Raise <br />Drilling Method O Mud Rotary � Air Rotary 0 Auger Cable Tool Push Point <br />Proposed Well Depth 50 ft Excavation in diameter Open Bottom <br />Conductor Casing in diameter / Conductor Casing Depth <br />Other <br />4 <br />Gravel Pack/Gravel Size <br />ft <br />N of borings <br />in diameter) <br />Well Casing Diameter 6 In Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br />Grout Seal Depth 50 ft m Neat Cement (94 Ib bag/5-10 gal water) Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) 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 />n Christy Box 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 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 />VIINUtUNI 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />j DEPARTMENT USE ONLY <br />Application Accepted By Date vr. <br />Grout Inspection ByDate 2 <br />Pump Inspection By Date <br />Soil Boring Inspection By Date <br />COMMENTS `S4,4fYJ 1?l: o 0Vt/00W erl3G, _si i14r1;ri4 . <br />Area 3 Employee ID# <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth _ftea__ ft <br />EHD043-06 10 25 2021 Cul*: I /A � 1r/% Well Pump Pcrmu <br />N <br />mm <br />D <br />v <br />v <br />m <br />m <br />W <br />ca <br />