Laserfiche WebLink
1 WELUPUMP 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 743 E. Critchett Ave. CITY/ZIP Tracy, "l 5 304 m <br /> u D <br /> CROSS STREET KaSSOn Rd. qpN 241-110-36 PARCEL SIZE 1�S LAND USE APPLICATION# <br /> m <br /> OWNER NAME Tami Tavake PHONE rn <br /> OWNER ADDRESS 743 E. Critchett Ave. CITY/STATE/ZIP Tracy CA, Q 5 304 <br /> CONTRACTOR Calwater Drilling Co., Inc PHONE (209)667-7932 <br /> CONTRACTOR ADDRESS 300 S. Kilroy Rd CITY/STATE/ZIP Turlock, CA 95380 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATE/ZIP <br /> 434218 5/31/2027 <br /> LICENSE �l C-57 ❑ C-61 ❑ D-09 El Other NUMBER EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING: ✓l;eneral Mineral/Coliform Bacteria(4391) Dibromochloropropane (4392). Arsenic(4393) <br /> INTENDED USE 2 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 QrReplacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ❑ New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Othef/ <br /> Proposed Well Depth 50o ft Excavation It in diameter ❑ Open Bottom it Gravel Pack/Gravel Size a-'( in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter \.a in Thickness/Gauge/ASTM Sched ❑ Steel Mastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Dep ft ❑ Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> entonitt-L e(20%solids) ❑ Other <br /> Grout Placement Method lyrrumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <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 /> Oli\1AI; Ai 211101 R VUA 1A( I. A01 R 1. RIJA IRI.0 I OR 1A�Pz )A"-1'd d <br /> EPARTMENT U E OPLy <br /> 41 Application Accepted By Date v� Area Employee ID# <br /> Grout Inspection By Date I flZb C SPECIAL Well Permit <br /> Pump Inspection By Date C WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS_- J Gt ,9'.-�Oeej LC <br /> t <br /> PE Sc Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cash Remitted I Service Request# <br /> s 3•a4 4 <br /> 43 4/ <br /> :r <br /> qk 4 <br /> 4 <br /> <� ` O CO,,. <br /> 4� <br /> Uploaded into Accela�* erm„ <br /> . <br /> EHD043-0604/07/2022 Page I of? <br />