Laserfiche WebLink
f WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 1 Q� l� /� 1 ao cc'rl l' f CITYIZIP Manteca, CA <br />CROSS STREET Dl1 V, EIS APN I)7�/ / `� PARCEL SIZE LAND USE APPLICATION # <br />OWNER NAME Loma Manteca } ��� ) II yy� C o f C G1 PHONE <br />OWNER ADDRESS <br />CONTRACTOR <br />130N. Santa Cruz Avenue Unit #G hjO) i l P", ler St <br />Krazan & Associates, Inc <br />CONTRACTOR ADDRESS 215 W. Dakota Avenue <br />SUBCONTRACTOR <br />Krazan & Assoviates, Inc <br />SUBCONTRACTOR ADDRESS 215 W. Dakota Avenue <br />LICENSE X C-57 '' C-61 11 D-09 1-I Other. <br />CITY/STATE/ZIP Los Gatos, CA IP74, "ijPc_G%S3 <br />559-348-2200 <br />PHONE <br />CITY/STATEIZIP Clovis, CA 93612 <br />PHONE 559-348-2200 <br />CITY/STATE/ZIP Clovis, CA 93612 <br />NUMBER 499908 EXPIRATION <br />10.31.2022 <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibrornochloropropane (4392) Arsenic (4393) <br />INTENDED USE Domestic/Private ( I Irrigation/Agricultural 1 Industrial Water Quality Monitoring r.1 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 />I::i Monitoring Well(s) # of wells I::1 Soil Boring(s) # of borings X Geotechnical 3 # or borings <br />Out -Of -Service Well IC Out -Of -Service Well Renewal Crosstorinection Repair (10-50Ft) <br />New Pump ❑ Pump Replacement Pump Repair :J Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method -: Mud Rotary ❑ Air Rotary Il Auger ❑ Cable Tool Push Point 01her <br />Proposed Well Depth 110 SJ ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br />- Conductor Casing in diameter / Conductor Casing Depth ft rp�(MENi <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel It C <br />Grout Seal Depth i D - 5 O ft X Neat Cement (94 lb bag15-10 gal water) Sand Cement sac mi r <br />Bentonite (20% solids) Cl Other j! 11.1 7 9n77 <br />Grout Placement Method I:; Pumped fa Free Fall Ll Other Retardant / Accelerator (name) <br />PEDESTAL Installed By 1-2 Driller ❑ Pump Contractor Other ENVIRONn,r_NrnL <br />I' Elli <br />Concrete Pedestal I iDimensions: Width ft Length ft Thick 11EA <br />LI <br />�in 0 Christy Box F Stove Pipe <br />PUMP % Submersible I Turbine 1.1 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: CPS <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 />k1#INIR1t N124 MOOR ADVANCE NOTICE REQVIRT.D FOR INSPECTIONS- PLEASE CALI, (2119) 953-7697 <br />DEPARTMENT USE ONLY <br />Application Accepted By r'1, Date <br />Grout Inspection By Date <br />Pump Inspection By Date <br />Soil Boring Inspection By Date <br />COMMENTS - fit Y,o,, l e 4 hf' (. .0W e 9 i <br />Area �� �� �' ft i6� Employee ID# <br />SPECIAL Well Permit <br />i WAIVER Received <br />Constructed Well Depth <br />/ i _ I <br />ft <br />;T <br />-4 <br />M <br />D <br />O <br />O <br />A <br />M <br />y <br />PE <br />Codes <br />SC Received Check#/ <br />Info B ash <br />Amount Date Permit/ Invoice # Well ID# <br />Rem ifie dService Request # <br /><ia <br />5"0 <br />CIO2 Z Z <br />EHD043-0604,'07/7022 Rge Ioft Feil; N—P Permit <br />