Laserfiche WebLink
1 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 2716 E. <br /> . Miner Avenue CrTY/ZIP Stockton, CA :4 <br /> CROSS STREET F3 !�(�r APN 143-44-002 PARCEL SIZE I I I�` LAND USE APPLICATION# op <br /> L,L mGrimaud Farms yOWNER NAME H✓ � Cee121 � PHONE <br /> OWNER ADDRESS <br /> 2716 E. Miner Avenue CITY/STATE/ZIP Stockton , CA 95205 <br /> CONTRACTOR Krazan &Associates, Inc PHONE 559-348-2200 <br /> CONTRACTOR ADDRESS 215 W. Dakota Avenue CITY/STATE/ZIP Clovis, CA 93612 <br /> SUBCONTRACTOR Krazan&Assoviates, Inc PHONE 559-348-2200 <br /> SUBCONTRACTOR ADDRESS 215 W. Dakota Avenue CITY/STATE/ZIP Clovis, CA 93612 <br /> LICENSE X C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER 499908 EXPIRATION DATE 10.31.2022 <br /> DOMESTIC WELL SAMPLING: i General Mineral/Coliform Bacteria(4391)i_ Dibromochloropropane(4392)11 Arsenic(4393) <br /> INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring YSoil Sam pling/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 Boring(s) #of borings X Geotechnical 3 #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair (20-50 Feet) <br /> ❑ New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION Q <br /> Drilling Method ❑ Mud Rotary 11 Air Rotary ❑ Auger 11 Cable Tool ❑ Push Point ❑ Other •` �)V <br /> Proposed Well Depth_Q J­50 ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size l r <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft R <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel Other <br /> Grout Seal Depth ?O-SO ft X Neat Cement(94 Ib ba9/5-10 gal water) El Sand Cement J lltix/7 g ater <br /> ❑ Bentonite(20%solids) El Other FAST•/�0'A' l COU ,— <br /> Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) �— <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal❑Dimensions:Width ft 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 IIOUR ADVANCE NOTICE:REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By N`��� Date q/�/ .7.�p Area S b k4Vi Employee ID# PIS <br /> Grout Inspection By Date Z Z ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date 1 Constructed Well Depth ft <br /> COMMENTS(-� be. 4-o N V�Gr I f rk-p r—1114r1'f ��O � P 11 f3iP t�� f� ��'`'/' LJOt 01- <br /> is <br /> r <br /> is C11CQ'u'gf�P- <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info Cash Remitted Service Resue # <br /> 37a Vi 7 O 2i 2 <br /> EIM043-06 04/07/2022 Page I of 2 Well/Pump Permit <br />