Laserfiche WebLink
1 II ?( ITrr <br /> WELL/PUMP PERMIT i -i Ti, <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZEl_TON AVENUE-STOCKTON CA 95205 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 974T25r�N Ashley Ln CITY/ZIP Stockton , CA 95212 m <br /> CROSS STREET R i l"ret`}` APN 0 8 6 4 8 0 3 7 PARCEL SIZE LAND USE APPuCA noN# A <br /> OWNER NAME Delattno� �J& Joy Gotelli Trust PHONE 209-931-4392 N <br /> OWNER ADDRESS -A.1 r•""" CITY/STATE/ZIP <br /> CONTRACTOR Purviance Drillers , Inc PH...E 209-887-3554 <br /> CONTRACTOR ADDRESS PO I,O X 64 CITY/STATE/ZIPL i n d e n , CA 95236 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE X C-57 U C-61 J D-09 D Other NUMBER 3 7 7 9 2 3 ExPIRAnoN DATE 7/31 /19 <br /> DOMESTIC WELL SAMPLING::.General Mineral/Coliform Bacteria(4391) DibromochlOropropane(4392)-.Arsenic(4393) <br /> INTENDED USE Domestic/Private C Irrigation/Agricultural C Industrial r Water Quality Monitoring f]Soil Sampling/Charactenzation <br /> C Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK n New Well C Replacement Well G Well Alteration/Modification J Other <br /> I'Monitoring Well(s) #of wells C Soil Boring(s) #oI borings C Geotechnical #of borings A <br /> U Out-Of-Service We([ C Out-Of-Service Well Renewal J Cross-Connection Repair <br /> New Pum C Pum R lacement C Pum Re air D Raise Well Casin 6.►� 1 S <br /> WELL CONSTRUCTION 0v�® <br /> Drilling Method A Mud Rotary r Air Rotary n Auger �l able Tool -1 Push Point n Other t') <br /> Proposed Well Depth 30D It Excavation�2 1� in diameter $'Open Bottom C Gravel Pack/Gravel Size in di;3meter f r �oe� <br /> Cl Conductor sing in diameter / Conductor Casing Depth ft �� AQU/ / <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched •1?(,Q Steel ,Plastic C Stainless Steel _i Other )v O <br /> Grout Seal Dept 00 ft C Neat Cement(94 lb bagl5-10 gal wale Sand Cement 11313 sack mix/7 g OQ,. UN� <br /> J Bentonite(20%solids) J Other <br /> Grout Placement Method umped D Free Fall D Other Retardant/Accelerator(name) �Nr <br /> PEDESTAL Installed By n Driller J Pump Contractor D Other <br /> C Concrete Pedestal CDimenslons:Width ft Length ft Thick in I Christy Box :i Stove Pipe <br /> PUMP D SubmersibleO Turbine 3 Other HP Pump Set ft Standing Water Level ft <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 1 AM IN COMPLIANCE WITH ALL <br /> WOR NS�ONW <br /> MINI 2 �NOTIC�EREQIJ_IRED FOR INSPECTIONS-PLEASE CALL(209)9 7 9SIGNE T,T�orporate SecretarcyA, Q/ 1718 <br /> J <br /> (11 Z1 <br /> /ss <br /> 4 <br /> c <br /> PA M E N T U,8 E CA LY <br /> Application Accepted By Date " Area Employee ID#JL <br /> Grout Inspection By �..`n �.. / Date�T� �f 6 _- SPECIAL W@II Permit <br /> Pump Inspection By Date ) WAIVER Received <br /> Soil Boring In action By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Receivea Amount ate Permit/ Invoice# WellID# <br /> Codes nfo B Cash Re itted Service Request# <br /> L, <br /> EHD 43-66 9/07/76 / , �// WILL/PU.\".P PERMIT <br />