WP0043762 - Laserfiche WebLink

Home Browse Search

ti 1 �r WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NUN-KEFUNDABLE PERMIT CALL LUy U0J-(by( FOR INSPECTIONS tXF'IKtb I YEAR FROM DATE ISSUED JOB ADDRESS __ 1406 East Taylor St_ _ ------ ------ —----------- c,n/Z,p Stockton 95205 'j - -------------------------- CROSS STREET S Sierra Nevada St APN /S/ - 31� ^ /� PARCEL SIZE O // LAND USE APPLICATION # OWNER NAME __C 1 t y of -S t O C k t o n------- ----- }PrH2ONEF__2_0R-93_7&411 ------- OWNER ADDRESS --- n�II E��aSt__abLeLA�}}Le------------------------ CITY/STATE/ZIP__ Sto_cck1.on _CKR52_02--------- CONTRACTOR LLYSZl..Q_LL1itQ��4�r�_—__-- — HONE _ 925-719-0822_ _ -------- -- — CONTRACTOR ADDRESS ' 1,♦7r2-+78 G� oll`deln,�_,VaIIey Parkway ......... CITY/STATE/ZIP --- It _r -,CA C19O5G33G0 __________ SUBCONTRACTOR _Weal oas ExplvratLQ�--------------- --------------- PHONE 207_985-75/4 I -------- SUBCONTRACTOR ADDRESS P.O. Box 133 -------- —___—__—__ CIT'Y//STATE/ZIP__EScalon,_CA 9 320_— LICENSE Xt C-57 ❑ C-61 ❑ D-09 ❑ Other ... ...... .... NUMBER �[ O�� EXPIRATION DATE—/��_! DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) C Arsenic (4393) INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization ❑ Public Water - ------ ----------------------------------- If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other ❑ Monitoring Well(s)—__—__ # of wells ❑ Soil Boring(s)# of borings X Geotechnical __2—__# of borings ❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair L New rump u me Li masse vveu uas Drilling Method ❑ Mud Rotary ❑ Air Rotary Xl Auger ❑ Cable Tool ❑ Push Point ❑ Other Proposed Well Depth_7-3Q__ft Excavation _—C__— in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter ❑ Conductor Casing ____ --- in diameter / Conductor Casing Depth Well Casing Diameter ____ in Thickness/Gauge/ASTM Sched _-------- ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other __— ------ —__ Grout Seal Depth__ 25-30__ft X Neat Cement (94 lb bag/5-10 gal wafer) ❑ Sand Cement --- —--- __ _sack mix/7 gal water ❑ Bentonite (20% solids) ❑ Other o4vA4F=NT Grout Placement Method ❑ Pumped ❑ Free Fall X Other Tremie ❑ Retardant / Accelerator (name) __-------- -- lk PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other +rn 9��` ❑ Concrete Pedestal ❑Dimensions: Width ft Length ft Thick 9E n ❑ Christy Box ❑ Stove Pipe PUMP ❑ Submersible[] Turbine ❑ Other HP Pump Set ft Standing Water LeVA)f^rT" u�rnHinat}: Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the following items: GPS Coordinates, property lines, adjoining properties, water bodies or courses, drainage pattern, roads, existing wells, structures, potential sources of contamination, sewers or private disposal systems. Include distance from two property lines. For Domestic, Agriculture, Industrial well, provide location of any water wells or surface water within 200' radius of proposed well. MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 DEPARTMENT US ONLY Application Accepted By _ Date -ZZ�� Grout Inspection By _ _——__—____ Date _—__ Pump Inspection By __ Date _—__—__t— —- Soil Boring Inspection By _ Date 10`�r ZAA COMMENTS ------------ ---------------------- — Area _r _v1 r _—_ Employee ID#_!"Iy� ❑ SPECIAL Well Permit ❑ WAIVER Received Constructed Well Depth ft PE SC Received C e k#/ Amount Date Codes Info Remitted Permit/ Invoice # Well ID# Service Request # /5-0 7 �� EHDO43-0604/072022 Page I oft Well %Punk Pennii