Laserfiche WebLink
WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468-3420 <br /> NON-REFUNDABLE PERMIT www.slqov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOBADDRESS 8766 N. Helen Ln CITYfLIPMorada 95212 y <br /> M <br /> CROSSSTREET Hildreth Ln qpN 08647001 jj�� D <br /> PARCEL SIZE I'I: LAND USE APPLICATION# <br /> 0 <br /> a <br /> OWNER NAME 67,' P-r_I I i F:J T L f t'_' PIT <br /> PHONE <br /> OWNERADDRESS �J�j7 Lcypr L"'j1lt2 CITY/STATEMPStoC)Cton,CA 95212 <br /> CONTRACTOR Purviance Drillers, INC PHQNE209-887-3554 <br /> CONTRACTOR ADDRESS P.O. Box 64 CITY/STATEIZIPL i nden CA 95236 <br /> SUBCONTRACTORICONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP <br /> LICENSE X C-57 C-61 _:D-09 1'Other NUMBER 377923 EXPIRATION DATE 7/31/21 <br /> BILLING PARTY: OWNER C CONTRACTOR ;: SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:G General Mineral/Coliform Bacteria(4391)Ll Dibromochloropropane(4392)1,Arsenic(4393) <br /> INTENDED USE f DomesGc/Private Irr gation/Agr cultural Industr al -Water Quality Monitoring [7 Soit Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well C Replacement Well Well Alteration/Modification Other <br /> _,Monitoring Well(s) #of wells 'i Soil Bo6ng(s) "borings ❑Geotechnical #of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> _1 New Pump Pump Replacement [I Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method L.Mud Rotary Air Rotary r Auger -Cable Tool C Push Point Other <br /> Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> -Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched Steel Plastic ^Stainless Steel 'I Other <br /> Grout Seal Depth ft -:Neat Cement(94 Ib bagIS-10 gal water) 7 Sand Cement sack mixr7 gal Water <br /> Bentonite(20%solids) :1 Other <br /> Grout Placement Method `;Pumped 'Free Fall 1.Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By '_Driller -Pump Contractor Other <br /> Concrete Pedestal CDimensions:Width ft Length It Thick In i Christy Box C Stove Pipe <br /> PUMP Submersible❑Turbine _Other HP Pump Set 1ei.0 It Standing Water Level ft <br /> I HEREBY CEWTIFY 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 /> ADVANCE NOTICE P.EOUIRE0 ' L � /r��_Pr EAS={:tit.!.- F7 997-71RT7 <br /> SIGNED TITLE V -/ DATE <br /> PAYMENT <br /> RECEIVED <br /> i SFS' 2 1 2020 <br /> IN JOAQUIN COUNTY <br /> s DEPARTMENT USE, ONLY ENVIRONMENTAL <br /> Application Accepted By �_ [.�— Date �, �c%Oi1� Area �1�% Employee ID# _NEALTH DEPARTMENT <br /> Grout Inspection By Date u SPECIAL Well Permit <br /> Pump Inspection By �' Date Il i f 1.C' n WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check* Amount PerrniU <br /> Codes In C sh Remitted Date Service Renest# Inv oice# WellID# <br /> 7 <br /> EHD43-M 6/11M19 <br /> WELL/PUMP PERMIT <br />