Laserfiche WebLink
JOB ADDRESS 18CS Fine Rd <br /> <br />City/Zip Lind Pn CA 9 ? 3 6 <br /> <br />CROSS STREET COPperopoli s Rd APN 18336037 <br /> <br />PARCEL SIZE .'" ' 7- LAND USE APPUCATION # <br />PHONE <br />orriSTATErii#JA nap n CA 9_5236 <br /> <br />OWNER NAME Jim Gleason <br /> <br />OWNER ADDRESS 185 S Pine Rd <br /> <br />CONTRACTOR Purviance Drillers, INC <br /> <br />p010Ne 209-887- 3554 <br /> <br />CONTRACTOR ADDRESS P.O. Box 64 ords,„mpLinden CA 95236 <br /> <br />SUBCONTRACTOR/CONSULTANT PHONE <br />SUBCONTFtACTOWCONSULTANT ADDRESS CITY/STATE/ZIP <br />LICENSE C-57 I C-61 I D-09 .. Other NUMBER 377923 EXPIRATION DATE 7 /31 /21 <br />BILLING PARTY: <br /> I I OWNER <br /> <br />CONTRACTOR U SUBCONTRACTOR/CONSULTANT <br />Proposed Well Depth ft Excavation in diameter LI Open Bottom [I Gravel Pack/Gravel Size in diameter <br />ft Thick <br />PEDESTAL <br />I Christy Box Ti Stove Pipe <br />Installed By 2 Driller Pump Contractor C Other <br />. Concrete Pedestal lDimensions: Width ft Length <br />WELL CONSTRUCTION <br />Drilling Method : Mud Rotary I Air Rotary Auger 7", Cable Tool IT. Push Point U Other <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter In Thickness/Gauge/ASTM Sched LI Steel U Plastic n Stainless Steel Other <br />Grout Seal Depth ft 7- Neat Cement (94 lb bag/5-10 gal water) E: Sand Cement sack mbc17 gal water <br />L Bentonite (20% solids) S Other <br />Grout Placement Method : Pumped 2, Free Fall I: Other 2 Retardant / Accelerator (name) <br />PUMP HP Submersible:' Turbine :-; Other C) Pump Set .)- g ft Standing Water Level L-IS ft <br />.2IGNED <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 COMPENSATI LAWS. <br />ADVANCE NOTICE REQUIRED ThISP - PLEASE CALL (2, <br />TITLE DATE <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE -SrocKroN CA 95205 -6232 (209) 468-3420 <br />NON-REFUNDABLE PERMIT www.sjgov.orgiehd EXPIRES 1 YEAR FROM DATE ISSUED <br />DOMESTIC WELL SAMPUNG: E. General Mineral/Coliform Bacteria (4391) 2 Dibromochloropropane (4392) Arsenic (4393) <br /> <br />INTENDED USE ypomestic/Private U Irrigation/Agricultural 2 Industrial Water Quality Monitoring 2 Soil Sampling/Characterization <br />2 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 I Well Alteration/Modification ;71 Other <br /># of brig Monitoring Well(s) # of wells I Soil Boring(s) ons Geotechnical # of borings <br />7. Out-Of-Service W II I Out-Of-Service Well Renewal 7! Cross-Connection Repair <br />U New Pump Pump Replacement Pump Repair Si Raise Well Casing <br />P°-- <br /> <br />I <br />ip Tr: r( <br />iiiiiiiiiiiiii 11 11115111iiiiii ii 11111111 :SSMJCICIV 311S DEPARTMENT USE ONLY <br />Application Accepted By Date //6/4"' <br />Grout Inspection By Date <br />Pump Inspection By Y "-.14; Date 1-11//247 <br />Soil Boring Inspection By <br />COMMENTS <br />Date <br />Area LI / €26; Employee ID# <br />0 SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth <br />ft <br />PE <br />Codes <br />SC <br />Info <br />Received \Chad,/ <br />Cash <br />Amount <br />Remitted Date Permit/ Invoice # Well ID# <br />1 ' ,•-, — <br />_Api <br />li1-314419-i " 7 i" LiL 0 !.! (12., ineR7T. <br />EHD 43-06 6/11/2019 WELL /PUMP PERMIT