Laserfiche WebLink
1 )113x1 fe- I��� WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUIY-RtFUNUAbLF_ PERMIT GALL ZUy 953-7697 FOR IN; <br />JOB ADDRESS NEAR: 3121 Monte Diablo <br />CROSS STREET Monte Diablo ,SklM1'Zt)APN 133-060-12 1 <br />OWNER NAME San Joaquin Area Flood Control Agency <br />OWNER ADDRESS 22 E Weber Ave #301 - <br />CONTRACTOR Geo -Ex Subsurface Exploration <br />CONTRACTOR ADDRESS 704 North Adams Street <br />TOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE R C-57 D C-61 D D-09 ❑ Other, <br />ECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />CITY/zip Stockton, CA 95203 <br />'.CEL SIZE 60 AC LAND USE APPLICATION # <br />PHONE 209-937-8113 <br />CITY/STATE/ZIP Stockton CA, 95202 <br />PHONE 916-799-8198 <br />CITY/STATVZIP Dixon, CA 95620 <br />PHONE <br />CITY/STATE/ZIP <br />NUMBER 954267 EXPIRATION DATE 7/31/2022 <br />DOMESTIC WELL SAMPLING: L General Mineral/Coliform Bacteria (4391) - Dibromochloropropane (4392) ❑ Arsenic (4393) <br />INTENDED USE 0 Domestic/Private 0 Irrigation/Agricultural ❑ Industrial 0 Water Quality Monitoring IX 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 D Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings N Geotechnical 12 # of borings <br />0 Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />D New Pump Pump ReDlacement ❑ PumD Reoair ❑ Raise Well Casino <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger D Cable Tool X Push Point ❑ Other <br />Proposed Well Depth g D ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched 0 Steel 0 Plastic ❑ Stainless Steel 0 Other <br />Grout Seal Depth 80 ft N Neat Cement (94 Ib bag/5-10 gal water) 0 Sand Cement sack mix/7 gal water <br />❑ Bentonite (20% solids) 0 Other Ii 1 wV AA C AIT <br />Grout Placement Method [X Pumped ❑ Free Fall 0 Other u Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor <br />❑ Concrete Pedestal []Dimensions: Width_ <br />in ❑ Christy Box ❑ Stove Pine <br />❑ Other. <br />It Length <br />R Thick <br />SMP 0 Submersible❑ Turbine ❑ Other HP Pump Set ft Standing Wa l'1� <br />Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the follo*W6RQWN1F- <br />Coordinates, property lines, adjoining properties, water bodies or courses, drainage pattern, roads, existintl PFAWW, <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 />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />//DEPARTMENT USE,NLY <br />Application Accepted By �� �� L to 3Area�vL{J Employee ID#_ <br />Grout Inspection By b�C L Date 0 SPECIAL Well Permit <br />Pump Inspection By Date 0 WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />PIE <br />Codes <br />SC Received <br />Info <br />Check#/ Amount Dat Permit/Invoice # <br />Sash Remitted Service R t # <br />Well ID# <br />37a <br />50 <br />alai 2 <br />F� <br />EHD043-06 04/07/2022 Page i of Well i Pump Permit <br />CA <br />m <br />g <br />A <br />N <br />N <br />