Laserfiche WebLink
I <br />e I <br />1 WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDARLF PERMIT r�Al I 113nni nem <br />— -- — rvn u�Jrct,IwrvJ t=ArIKtb 7 YEAR FROM DATE ISSUED <br />JOB ADDRESS 7007 Pezzi Road CITY2IP Stockton / 95215 <br />CROSS STREET Waterloo Road ApN 089-060-65 PARCEL SIZE 14.98 LAND USE APPLICATION # <br />OWNER NAME Linden Unified School District <br />PHONE 209.887.3894 <br />OWNER ADDRESS 18527 E. Main Street CITY/STATE/zIP Linden, CA 95236 <br />CONTRACTOR V & W Drilling - Contact: Karli Stroing, President PHONE 209.981.7755 <br />CONTRACTOR ADDRESS 1133 Blackhurst Drive CITY/STATE/ZIP Galt, CA 95632 <br />SUBCONTRACTOR Condor Earth - Contact: Ron Skaggs, CA PE #44588/GE #2295 PHONE _209.601.1430 (Cell) <br />SUBCONTRACTOR ADDRESS 188 Frank West Circle, Suite I CITY/STATE/ZIP Stockton, CA 95206 <br />LICENSE IXC -57 ❑ C-61 0 D-09 L Other NUMBER 720904 EXPIRATION DATE 04/30/2022 <br />DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) ❑ Arsenic (4393) <br />INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br />C Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK ❑ New Well ❑ Replacement Well C Well Alteration/Modification C Other <br />0 Monitoring Well(s) # of wells C Soil Boring(s) # of borings X Geotechnical 1 # of borings <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair ^ <br />l New Pum 7 Pum Replacement ❑ Pum [IRe air Raise Well CasingPA <br />WELL CONSTRUCTION <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary X Auger ❑ Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth 10, ft Excavation 4 1/2 in diameter C Open Bottom ❑ Gravel Pack/Gravel Size___*Rd ter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft SAN <br />" J ` <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched , Steel ❑ Plastic C Stainless Steel Other ❑Cq <br />Grout Seal Depth i ft X Neat Cement (94 Ib bag/5-10 gal water) C Sand Cement <br />❑ Bentonite (20% solids) X Other Trenlie EpAR C <br />Grout Placement Method ❑ Pumped ❑ Free Fall C Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By _— Driller ❑ Pump Contractor Other <br />C Concrete Pedestal 7Dimensions: Width ft Length ft Thick <br />in ❑ Christy Box E Stove Pipe <br />PUMP C 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 L <br />Application Accepted By Date Area Ci �% Employee ID# <br />Grout Inspection By X1 yDate Z Z ❑ SPECIAL Well Permit <br />Pump Inspection By ll, Date ❑ WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />PE SC Received Check#/ Amount Permit/ <br />Codes Info Elm Cash Remitted Date Service e uest # <br />Invoice # Well ID# <br />R <br />I <br />i ra <br />/�i77�7s� ge t or[ <br />/ Well / Pump Permit <br />. <br />T <br />1 <br />M <br />n <br />0 <br />v <br />z <br />m <br />N <br />VT <br />'D <br />1Ty <br />/t <br />