Laserfiche WebLink
Area q Employee ID# it <br /> <br />1 SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1668 EAST HAZELTON AVENUE - STocKTON CA 95205 -6232 (209)468-3420 <br />NON-REFUNDABLE PERMIT WWW.SiQO <br />JOB ADDRESS 13030 N Devries Rd cirdzip Lodi CA 95242 , <br />CROSS STREET Tredway Rd ApN 05523004 PARCEL SIZE 1 .34 LAND USE APPLICATION # <br />OWNER NAME Carlos Figueroa PHONE ?e ri - S-46- 3y zcq <br />OWNER ADDRESS 1 3 0 3 0 N Devries Rd CITYISTATERIP_LOdi CA 95242 , <br />CONTRACTOR Purviance Drillers, INC pHoNE209 -887 -3554 <br />CONTRACTOR ADDRESS P • 0 - Box 64 crryisTATEizipLinden CA 95236 <br />SUBCONTRACTOR/CONSULTANT PHONE <br />SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATEMP <br />LICENSE x C-57 2 C-61 __ D-09 Other NUMBER 377923 EXPIRATION DATE 7 /3 1 /2 1 <br />BILLING PARTY: 2 OWNER _ CONTRACTOR , . SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: i: General Mineral/Coliform Bacteria (4391): Dibromochloropropane (4392)1 I Arsenic (4393) <br />INTENDED USE -: Irrigation/Agricultural r: Industrial : Water Quality Monitoring t) Soil Sampling/Characterization .,CDomesticiPrivate <br />: Public Water System <br />If different from Owner Water System Name , Contact Name or Phone Number <br />TYPE OF WORK ' New Well ). Replacement Well : Well AlterationlModification - ) Other a 4' A : Monitoring Well(s) # of wells : Soil Boring(s) of borings ) Geotechnical of borings <br />.. Out-Of-Service Well ' , Out-Of-Service Well Renewal ./ Cross-Connection Repair <br />: New Pump (Pump Replacement . Pump Repair 2 Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method _. Mud Rotary .: Air Rotary , Auger :2 Cable Tool I.-2. Push Point Li Other <br />Proposed Well Depth ft Excavation in diameter lit Open Bottom Gravel Pack/Gravel Size in diameter .1 <br />: Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Schad Steel ri Plastic 11 Stainless Steel 1 Other <br />Grout Seal Depth ft ' I Neat Cement (94/b bag/5-10 gal water) ri Sand Cement sack mix/7 gal water <br />)2 Bentonite (200/0 solids) j Other <br />Grout Placement Method 1: Pumped -. Free Fall L Other .. Retardant I Accelerator (name) <br />PEDESTAL Installed By 7 Driller I Pump Contractor r: Other <br />.: Concrete Pedestal _.Dimensions: Width ft Length ft Thick in : Christy Box I Stove Pipe <br />PUMP 're...Submersible 2 Turbine ri Other HP 1 -',...-;-- Pump Set '1:> 0 ft Standing Water Level Li <br />I HEREBY CERTIFY THAT <br />JOAQUIN COUNTY ORDINANCES, <br />CURRENT AND ACTIVE <br />WORKERS COMPENSATION <br />SIGNE& /...) d <br />WITH <br />I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />S. <br />7!.7-7P,-:'177CAn 1:2r‘ • -77 , <br />--LA_. A .A. .4...2...4_>-4,._ Tits (..., rt C/6-e_ <br />- 1 <br />. ri <br />7, <br />0 ,..,_ :SS3NOCIV 3.1.1$ DEPARTMENT USE ONLY <br /> <br />Application Accepted By Date 7// (1/4 / <br /> <br />Grout Inspection By Date <br /> <br />Pump Inspection By Date <br /> <br />Soil Boring Inspection By Date <br />COMMENTS <br />PE <br />Codes <br />SC <br />Info <br />Received Check#/ <br />ash <br />Amount <br />Remitted pat Permit/ <br />Service Re ues # Invoice # Well ID# <br />‘ <br />/I Lk <br />WELL /PUMP PERMIT 1.2-s3ck5- / 7/