Laserfiche WebLink
HH '°N AdSt:b LIH 'Z '}Dp @U111 paAl)a� vo <br />WELLIPUMP PERMIT <br />SAN JOAOUIN COUNTY EmviRONmENTAL HEALTH DEPARTmekT 1868 EAST HAZELTON AVENUE- STOCKTON CA 95205 - (209) 4663420 <br />N-KEFUNDABLE rl::K In (.ALL IIZUU) y53 -/105l FORINSPECT70NS tX!'IXtS 'I YEAR FROM DATE ISSUED <br />ADDRESS 11646 Sun Rd '1 j 1 'l. (� cITYlLP S t O C k t O n CA 95215 <br />53STREEr B e a c h e r Rd APN 1, 3 <br />D TO WA PARCEL S¢E tAxD Use AprucATtoN A <br />IER NAME Mark McCormack P111E209-662-2126 <br />ER ADDRESS 11646 Sun Rd CI7YlSTATElzIP Stockton CA 95215 <br />CONTRACTOR Purviance Drillers, Inc. <br />CONTRACTOR ADDRESS P.0 B O x 64 <br />CONTRACTOR <br />1CTOR ADDRESS <br />X: Cbl ! C-67 D-09 <br />PNON;09-887-3554 <br />CITYIS-rAwlZip Linden, CA 95236 <br />PRONE <br />CITY/STATEIZIP <br />NuMsER 32291-3-- FXPIRATION <br />GEOGRAPHICAL INFORmA-nom: Coordinates X Y Township_ Range Section <br />INTENDED US £ At Demestic/Private InigatloNAgriruritural r! Industrial O Water Quality Monioring 11 Soil Sampling/Characterization <br />_ Public WaterSystaD <br />rrdilfcrent ham Owner wae' ysem N.M. arra ar one uFl <br />TYPE OF WORK L New Well _ Replacement Wall L. Well AlteratiorJfiAodifiration t. Other <br />Monitoring WeI of wells 7r SoilBoring(s) "o1Dotings I Gentechn:cal a°ro°nags <br />_, Out -Of -Service Well i i Out-OfService Well Renewal r. Cross -Connection Repair <br />Now Pump a Fcmp Replacement _ Pump Repair i:: Raise Well Casio <br />Drilling Method Mud Rotary Air Rotary i Auger -, Cable Tool -i Push Point l; Other <br />Proposed Well Depth ft Excavation in diameter _ Open Bottom G Gravel Pack/Gravel Size in diameter <br />-Conductor Casing in diameter 1 Conductor Casing Depth tt <br />Wall Casing Diameter_ in Thicknass/GaugeAASTM Sched = Steel a Plastic ' Stainless Steel G Other <br />Grout Seal Oepth R _ Neat Cement (941b 6sg/5-10 gel ivalerj _ Sard Cement sack rniyJ7 gal water <br />- Bentorite(20%solids) Other <br />Grout Placement Method Pumped = Free Fall ^ Other .-i Rel wdaniIAccelerator (name) <br />D ST L Installed By I: Driller Pump Contractor C Other <br />:Con cr2te Pedestal -Dimensions Width It Length n Thick it Christy Bax LI Stove Pipe <br />PUMP 91kSutrnersihteu Turbine v Other HP itE PumpSet It Standing Water Level k <br />I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I Am IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LA1LlS- <br />M1NI �M��24 KQU! A ANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209) 953-7697 <br />SIGNED _ !�^-?��� .GGr�c-zyf-.�.- Trn.E C o r p Secretary DAT2= /0-2-/7 <br />DEPARTMENT USE ONLY <br />Application Accepted By Date ry l7 Area-_ - Employee lctr Wdn <br />Grout Inspeaon By Date D. SPECIAL Well Permit <br />Pump Inspection By VA Date ❑ WAIVER Received <br />Soil Baring Impoction By Date Constructed Well Depth it <br />COMMENTS <br />m <br />D <br />a <br />to <br />m <br />PE <br />Codes <br />SC Received <br />info B <br />Check*/ <br />Cash <br />Amount <br />Remitted <br />Date Permit! <br />-eeRe st# <br />lnwice# Wag ID# <br />331 <br />S0 <br />�� <br />7-7 <br />I0 <br />" <br />EHO a}76 <br />ar3Clt2 <br />Z -d <br />tZ5CZ2960Z <br />' q -D <br />Y(ELLrP INP PERMIT <br />out s1811uQ 801.1181Aind dCt:tO Z L ZO lo0 <br />