Laserfiche WebLink
WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)4683420 <br /> NON-REFUNDABLE PERMIT www.sigov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> 8600 N. Duncan Rd Linden, 95236 <br /> JOB ADDRESS CITYIZIP m <br /> D <br /> CROSS STREET Messick Rd APN n(nSl l[1nc�� PARCEL SIZE,�- LAND USE APPLICATION# v <br /> Garett Becker 209 604 2222 <br /> OWNER NAME PHONE re <br /> OWNERADDRESS P.O. Box 145 CITYISTATE17JP Linden,Ca 95236 <br /> CONTRACTOR Purviance Drillers, INC PHONE 209-887-3554 <br /> CONTRACTOR ADDRESS P-O. BOX 64 CIrY/STATEMPL i nden CA 95236 <br /> SUBCONTRACTORICONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CrtY/STATEIZIP <br /> LICENSE X C-57 C-61 i D-09 C Other NUMBER 377923 EXPIRATION DATE 7/3 1/2 1 <br /> BILLING PARTY: �]OWNER :i CONTRACTOR SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING:i General Mineral/Coliform Bacteria(4391)[i Dibromochloropropane(4392)G Arsenic(4393) <br /> INTENDED USE Domestic/Private ❑ Irrigation/Agricultural i;Industrial Water Quality Monitoring C Soil Sampling/Characterization <br /> Public Water System p �� <br /> If different from Owner. Water System Name Contact Name or Phone Number ♦ . <br /> TYPE OF WORK :: New Well I Replacement Well C Well Alteration/Modification Other E�l ,�N <br /> - Monitoring Well(s) #of wells 0 Soil Boring(s) 4 of bOflnes :1 Geotechnical 4 of bonne' V/ D <br /> Out-Of-Service Well 0 Out-Of-Service Well Renewal :i Cross-Connection Repair AUG 3 <br /> New Pum -'Pum Replacement Pum Re 7,it n Raise Well Casing312020 <br /> WELL CONSTRUCTION Sq <br /> Drilling Method :Mud Rotary Air Rotary Auger C Cable Tool Push Point J Other N JOA (N CO <br /> Proposed Well Depth ft Excavation in diameter i I Open Bottom L Gravel PacklGravel Size�j4pi MENTAL Ty <br /> - .Conductor Casing in diameter ! Conductor Casing Depth ft PARTMENT <br /> Well Casing Diameter_in ThidmeWGauge/ASTM Sched 7 Steel "..:Plastic Stainless Steel a Other <br /> Grout Seal Depth ft 71 Neal Cement(94 lb bag45-10 gal water) 7 Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) ❑Other <br /> Grout Placement Method -Pumped -i Free Fall C Other Retardant!Accelerator(name) <br /> PEDESTAL Installed By _Driller _Pump Contractor C Other <br /> Concrete Pedestal-Dimensions:Width ft Length ft Thick in _Christy Box -Stove Pipe <br /> PUMP Submersible^Turbine _Other HP Pump Set ft Standing Water Level1�ft <br /> I HEREBY CERTIFY THAT I 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 LAWS. <br /> R AJ!'VANC=NInTInf!F?r_nl)Ir'r_r, <br /> SIGNED � 'U� TITLEDATE ..0/2 YZze <br /> I kH <br /> DEPARTMENT USE. ONLY <br /> Application Accepted By ` /�L—G� Date a �1/1'L 0 Area � Employee ID# <br /> Grout Inspection By Date 1 SPECIAL Well Permit <br /> i <br /> Pump Inspection By 1 rS.,. Date r�� ( ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth It <br /> COMMENTS <br /> PE Sc Received Check#/ Amount Date Permrt/ <br /> Codes Info sh Remitted Service Reuest# Invoice# Well ID# <br /> �13t' 31 , <br /> EHO 43-06 6!1 V2019 <br /> W - //��7,/0 ` WELL/PUMP PERMIT <br />