Laserfiche WebLink
I 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 4151 Logan Lane CITY/zIP Stockton, CA 95206 <br />CROSS STREET Nemaha Way ApN 17 918 018 PARCEL SIZE 5 . 6 9 LAND USE APPLICATION # <br />OWNER NAME City of Stockton, Municipal Utilities Dept. PHONE 209-937-8787 <br />OWNERADDRESS 2500 Navy Drive CITY/STATE/ZIP Stockton, CA 95206 <br />CONTRACTOR ENGEO PHONE 916-786-8883 <br />CONTRACTOR ADDRESS 2213 Plaza Drive CITY/STATE/ZIP Rocklin, CA 95765 <br />SUBCONTRACTOR Geo -Ex Subsurface Exploration PHONE 916-799-8198 <br />SUBCONTRACTOR ADDRESS 1510 Madera Drive CITY/STATE/ZIP Dixon, CA 95620 <br />LICENSE X C-57 I C-61 ❑ D-09 ❑ Other NUMBER 954267 EXPIRATION DATE 0 7— 3 1— 2 0 2 2 <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) - Dibromochloropropane (4392) i Arsenic (4393) <br />INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring X 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 Borings) # of borings X Geotechnical 1 # of <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair REc Icv'I1 iI Y <br />❑ New Pum 11 Pump Replacement ❑ Pum Repair i Raise Well Casing` V <br />WELL CONSTRUCTION APR <br />Drilling Method XMud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other 9 %ni <br />Proposed Well Depth 50 ft Excavation 4 in diameter . ❑ Open Bottom ❑ Gravel Pack/Gravel Siz �AN J/diameter <br />Well Casing Diameter in <br />Casing <br />in diameter / Thickness/Gauge/ASTM Sched Conductor Casing Depth <br />Steel ❑Plastic ❑Stainless Steel ❑ Othet ry flENMENT L <br />Grout Seal Depth 5 0 ft XNeat Cement (94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal wa <br />❑ Bentonite (20% solids) ❑ Other Borings will be backfilled to the ground surface using tremie metho <br />Grout Placement Method X Pumped ❑ Free Fall with neat cement fill <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other Not applicable <br />❑ Concrete Pedestal ❑Dimensions: Width It Length ft Thick <br />�in ❑ 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 />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />DEPARTMENT USE ONLY <br />Application Accepted By C � �_- _ Date a?oZ Area llsfuklvil Employee ID#AG <br />Grout Inspection By Date ❑ SPECIAL Well Permit <br />Pump Inspection By Daten M ❑ WAIVER Received <br />Soil Boring Inspection By44Y-V <br />ate W 1, ` 610 Constructed Well Depth It <br />COMMENTS <br />ds <br />PE <br />Codes <br />Sc Received Check#/ <br />Info Cash <br />Amount <br />Remitted <br />ate Permit/ Invoice # Well ID# <br />Service gequest # <br />y a <br />l'so <br />ys6 <br />,7.o <br />EHDO43-06 04/07/2022 n -7 Page I of 2 Well / Pump Permit <br />/7/LL//�3(aJT <br />