Laserfiche WebLink
. 1 WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN-KEFUNDABLE PERMIT GALL (ZU9) 953-7697 FOR INSPECTIONS EXPIRES 7 YEAR FROM DATE ISSUED <br />JOB ADDRESS 445S San Joaquin Street CITY/zIP Stockton, CA <br />CROSS STREET rP nno(7} APN 41< Z) 03 PARCEL SIZE ♦ ) LAND USE APPLICATION # <br />OWNER NAME Gospel Center Rescue Mission PHONE <br />OWNER ADDRESS <br />445 S San Joaquin Street CITY/STATE/ZIP Stockton, CA 95203 <br />CONTRACTOR Krazan & Associates, Inc <br />CONTRACTOR ADDRESS 215 W. Dakota Avenue <br />SUBCONTRACTOR Krazan & Assoviates, Inc <br />SUBCONTRACTOR ADDRESS 215 W. Dakota Avenue <br />LICENSE X C-57 ❑ C-61 ❑ D-09 ❑ <br />PHONE 559-348-2200 <br />CITYISTATE/ZIP Clovis, CA 93612 <br />PHONE 559-348-2200 <br />CITYISTATE/ZIP Clovis, CA 93612 <br />NUMBER 499908 EXPIRATION DATE 10.31.2022 <br />DOMESTIC WELL SAMPLING: iI General Mineral/Coliform Bacteria (4391) 1 i Dibromochloropropane (4392) i i Arsenic (4393) <br />INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ 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) # of borings X Geotechnical 1 of borings <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair (50 feet) <br />❑ New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other ' • <br />Proposed Well Depth$ c7 ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size. in Ti r <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft r t Ali' z , ?O <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched ElSteel El Plastic Plastic Stainless Steel her <br />Grout Seal Depth :a D ft X Neat Cement (94 Ib bagIS-10 gal water) ❑ Sand Cement ffiQ&1j((168aI water <br />❑ Bentonite (20% solids) ❑ Other H�T�RONM�N, Nei' <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 />NINIMU1t 24 HOUR ADVANCE, NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />l DEPARTMENT USE ONLY <br />Application Accepted By 1�1� Date V-2 1/W-2 <br />Grout Inspection By J Date i L <br />Pump Inspection By Date <br />Soil Boring Inspection By Date <br />COMMENTS J.erwf.G1017 <br />1S <r+YtCVV f `nV <br />Area I 57JGk�vr^ EmployeeID#/77� <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well <br />ft <br />TZ <br />m <br />g <br />O <br />A <br />m <br />y <br />PE Sc Received Check#/ <br />Codes Info Cash <br />Amount Date <br />Remitted <br />Permit/ Invoice # Well ID# <br />Service Request # <br />W 37d C5 0 <br />EHD043-06 04/07/2022 ,) / / y Page I of 2 Well /Pump Permit <br />