Laserfiche WebLink
1 WELL/PUMP PERMIT 2255 <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 /> rn <br /> JOB ADDRESS 28455 Corral Hollow Rd. CITY/ZIP Tracy/95377 m <br /> D <br /> CROSS STREET W. Linne Rd. APN 240-14-021 PARCEL SIZE 1.95 �LA�ND USE APPLICATION# <br /> OWNER NAME RetechNerizon - Contact Marla Sullivan jV a- Te)eGy�1HONE 916-833-3066 <br /> OWNER ADDRESS 11375 Sunrise Park Dr. Ste. 600 CITY/STATE/ZIP Rancho Cordova/CA/95742 <br /> CONTRACTOR Delta Pump Inc PHONE 209-4�]66-9625 <br /> CONTRACTOR ADDRESS 646 S California St. CITY/STATE/ZIP StOCktOn/95203 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C-57 X C-61 - D-09 : Other NUMBER 1055434 EXPIRATION DATE 7/31/2023 <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)❑Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE x Domestic/Private Irrigation/Agricultural -. Industrial Water Quality Monitoring L; Soil Sampling/Characterization <br /> Public Water System <br /> PAI - <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well 71 Replacement Well ❑Well Alteration/Modification o Other <br /> Monitoring Well(s) #of wells 0 Soil Boring(s) #of borings F. Geotechnical 9 oforings <br /> Out-Of-Service Well ❑ Out-Of-Service Well Renewal 11 Cross-Connection Repair MAY ? ?� <br /> i New Pump K Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION FNVIRQ U/N CO, <br /> Drilling Method Mud Rotary - Air Rotary Auger Cable Tool Push Point Other HEgLT NP,1tN Ty <br /> Proposed Well Depth ft Excavation in diameter ❑ Open Bottom Gravel Pack/Gravel Size in i -fe T <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched Steel ❑ Plastic i] Stainless Steel Other <br /> Grout Seal Depth ft Neat Cement(94 Ib bag/5-10 gal water) 0 Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method C Pumped - Free Fall Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By -- Driller l; Pump Contractor Other <br /> L Concrete Pedestal Li Dimensions:Width ft Length ft Thick <br /> in Christy Box -. Stove Pipe <br /> PUMP C Submersible.- Turbine r1 Other HP Pump Set 244 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 /> NII',INit NI 24 11/11 R WN I \0 1 l( 1 111'Q 'IRED FOR INSPF.("1'IONS-11I1-ASt:CALL(209)953-7697 <br /> DEPARTMENT USE ONLY Q <br /> Application Accepted By �LL Date a a� Area Employee ID# <br /> Grout Inspection By Date_ ❑ SPECIAL Well Permit <br /> r <br /> Pump Inspection By , Date ❑ WAIVER Received <br /> Soil Boring Inspection By 1 Date Constructed Well Depth ft <br /> COMMENTS L c>cy C*1 C'anfG�tnc4fe rS v✓Eill <br /> PE SC Received eck#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By Remitted Service Request# <br /> L4 381 sa 7-7 <br /> [:I IIT U3 lk 102 20-21 PaEc 1 of \Fell.Nnnr I......t <br />