Laserfiche WebLink
t <br />L M " N AdSti:E 810 9 �A au)Ili p;Aia ad <br />WELUPUMP PERMIT <br />SAN JOAgWN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1858 EASTH-(-TON AVENUE- STOCKTCW CA 95205 - (209) 468-3420 <br />rvVrv-KEFUNDABLE PERMIT GALL "109 955-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JosADDREss L7485 E Cherokee Rd CmIbP Stockton, CA <br />CRWS STREET A S 111 e y APN - /Aj3 _PAR CEL SIZE AD" USE APPOCAT1oN a <br />OWNER NAME Robert Freeman PHONE 209-481-5872 <br />OWNER ADDRESS 16323 E Baker Rd CITY(STATIUMP Linden, CA 95236 <br />NTRACTOR Purviance Drillers, Inc <br />NTRACTOR ADORFSs PO B O x 64 <br />8CONTRACTOR <br />amNTRACTOR ADDRESS <br />ENSE X C-57 D C-61 <br />J D-09 ❑ <br />PIiOME 209-8187-3554 <br />CITYISTAT _r,pL i n d e n, CA 9 5 2 3 ( <br />PHONE <br />CITYISTATEMP <br />NumsER 3 7 7 9 2 3 EXPIIRA71CN DA <br />7/31/19 <br />DOMESTIC WELL SAMPLING- E General Mineral/Coliform Bactena (4391) L Dibramochloropropane (4392) :1 Arsenic (4393) <br />INTENOED USE n Dumestici'Private Irrigation/Agricultural G Industrial n Water Quality Monitoring 7 SON Sampling/Characterizati an <br />a Public WaterSyet m A <br />Irtlit1—nl rmm Owner. Water System No— Contact Naas m Plane NtmDor <br />TrDE OF WORK D New l'VelI C Replacement Well U Well AlteratlorJModifiealion 7 Other <br />G Monitoring Well(S) # of wells D S61 6oring(s) 11 m bOrl- ❑ Geoleehnicat a or boKnps <br />D Out-01-5ervioeVMI D Out -0l -Service Well Renewal ❑ Cross-Connecti Repair <br />` <br />D New Pump 12JPuri) ReDlacemeni n Pumn Ranair n P'i" Won r,.a;— MA <br />Drilling Method P Mud Rotary I, Air Rotary D Auger D Cable Tool n Push Point G Other -9N <br />Proposed Well Depth tt Excavation in diameter C Open Bottom n Gravel Pack/Gravel Size_ <br />D Conductor Casing in diameter I Conductor Casing Depth a ACTh p <br />Well Casing Diameter_ in Thichness/GaugerASTM Sched C Steel I] Plastic U Stainless Steel J Other <br />Grout Seal Depth R U Neat Cement (.94 1b beg/5-10 g8(water) D Sand Cement sack mix(7 gal water <br />D Berlonite (20% solids) ❑ Other <br />Grout Placement Method D Pumped D Free Fall D Other C Retardant I Accelerator (name) <br />PEDESTAL Installed By 0 Dri'ler D Pump Contractor O Other <br />U Concrete Pedestal ❑Dimensions: Widlh R Length R Thick irt, 7 ChristYBOK U Smve Pipe <br />EYME D SubmersibleXfurbine 7 OtherHP Pump Set fl Standing Water Level ry <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL HE 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 1 AM IN COMPLIANCE WITH ALL <br />WORKS ENSATION LAWS. <br />MINIMU 24 HO A E NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />s,DNEo___ rTL�orporate Secretar&„E 3/6/18 <br />rA <br />D <br />fn <br />m <br />0? 47 <br />418 <br />IN CO <br />MFNrUN�Y <br />DEPARTMENT S NLY <br />Applicetlon Accepted By Dade ArealL_C �L _ Employee ID# <br />Grout Inspector By Date 14 11 SPECIAL W®11 Permlt <br />Pump Inspection By Dale Y L1 WAIVER R@CAiV@d <br />Soii Boring Inspection By Date (J Construcled Well Depth R <br />CC MPAENTS <br />EHD 4ws M1015 C ^i- -:f 7G 3`fo3 ¢3 <br />WE'_L/PJMPPERMr <br />HEALTH <br />-S <br />b'd VLSCZ2960Z out eoueiA.lnd dLE:VO 2 6 90 aeW <br />