Laserfiche WebLink
WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468-3420 <br /> NON-REFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 1218 Beecher Rd crrymp Stockton,CA 95215 m <br /> CROSS STREET Finkbohner Rd APh 10320030 PARCEL SIZE D <br /> LAND USE APPLICATION o <br /> A <br /> OWNER NAME John Armani nc) PHONE vi <br /> OWNER ADDRESS 1271 N_ BperhPr RH CrTY/STATE21P Stockton,CA 95215 <br /> CONTRACTOR Purviance Drillers, INC PHOME209-887-3554 <br /> CONTRACTOR ADDRESS P.0• BOX 64 CITY/STATE21PLinden CA 95236 <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTORICONSULTANT ADDRESS CITYISTATE2IP <br /> LICENSE X C-57 "C-61 D-09 :i Other NUMBER 377923 EXPIRATION DATE 7/3 1/2 1 <br /> BILLING PARTY: OWNER ^CONTRACTOR L3 SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:G General Mineral/Coliform Bacteria(4391).�Dibromochloropropane(4392)0 Arsenic(4393) <br /> INTENDED USE 7. Domestic/Private ❑Irrigation/Agricultural r Industrial C Water Quality Monitoring C Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK C New Well L Replacement Well ::Well Alteration/Modification C Other <br /> D Monitoring Well(s) #of wells L Soil Boring(s) #of bonngs Geotechnical 9 of borings <br /> 7 Out-Of-Service Well Out-Of-Service Well Renewal C Cross Connection Repair <br /> New Pum L Pump Replacement .-�Pump Repair 7 Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary i]Air Rotary D Auger C Cable Tool C Push Point I] Other <br /> Proposed Well Depth ft Excavation in diameter C Open Bottom D Gravel PacklGravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad Steel it Plastic C Stainless Steel Ll Other <br /> Grout Seal Depth ft D Neat Cement(94/b bag/5-10 gal water) D Sand Cement sack mix/7 gal water <br /> ;:Bentonite(20%solids) D Other <br /> Grout Placement Method .-i Pumped :,Free Fall Other [:Retardant/Accelerator(name) <br /> PEDESTAL Installed By L Driller L Pump Contractor L Other <br /> Concrete Pedestal LDimenslons:Width ft Length ft Thick in Christy Box C Stove Pipe <br /> PUMP D Submersible:.-Turbine C Other. HP Pump Set ft Standing Water Level=L�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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATI N LA <br /> C'r-1`7QU . '1'AAtJ- CALL <br /> SIGNED TITLE'( CL DATE Z- <br /> YMENT <br /> F77 11 CEIVED <br /> J AQUIN COUNTY <br /> LTAL <br /> H DEPARNVIRONMETMENT 61 1 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By i Date l:.�L?h/j i. Ci Area �C' Employee ID# } <br /> Grout Inspection By Date L1 SPECIAL Well Permit <br /> Pump Inspection By ��e ,; ,�y c ;jDate 1 e LA Ii,yo ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Ch¢ck#/ Amount Permitl <br /> Codes/ �Info Date 11 Cash Remitted S rvlC Re uest# Invoice# Well ID# <br /> rJ l IJV <br /> %'41, <br /> 1 I <br /> Oil 11 Q <br /> EHO43-06 6/11/2019 <br /> WELL(PUMP PERMIT <br />