Laserfiche WebLink
WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCICTON CA 95205.6232 (209) 468-3420 <br />NUN-KEFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 2097 Bever -Ln--- crTv2tPStockton, CA 95215 <br />CROSS STREET Waterloo Rd �1 APN 10122051 PARCEL SIZE 4 7 - 6 LAND USE APPLICATION # <br />OWNER NAME Tom C c)t- 11 � �+-� J 1 �'C��I)iL l Al<1tC j L1 �Z PHONE <br />OWNER ADDRESS 2097 Beyer Ln Cm'/STATE/ZIPStock f on, CA 95215 <br />CONTRACTOR Purviance Drillers, INC PHONE209-887-3554 <br />CONTRACTOR ADDRESS P - 0- BOX 64 CrrY/STATE/ZIPL i nden CA 95236 <br />SUBCONTRACTORICONSULTANT <br />PHONE <br />SUBCONTRACTORICONSULTANT ADDRESS CITYISTATEIZIP <br />LICENSE R C57 C-61 _ D-09 I Other NUMBER 377923 EXPIRATION DATE 7 / 3 1 / 2_ <br />BILLING PARTY: i OWNER ] CONTRACTOR G SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: G General MineraVColiform Bacteria (4391)1: Dibromochloropropane (4392) ❑ Arsenic (4393) <br />NTENDED USE E Domestic/Private gation/Agricultural ;; Industrial ;; Water Quality Monitoring ❑ Sal Sampling/Characterization <br />Public Water 5ySteTn <br />If different from Omer Water SyStem Name Contact Name ar Phone Number <br />I. yr r• , rveW vveii i.: Keplacement wen L I Well Alteration/Modification i i Other <br />11 Monitoring Well(s) # of wells ❑ Soil Boring(S) # of borings C Geotechnical # of borings <br />Out -Of -Service Well Cl Out -0f -Service Well Renewal Cross -Connection Repair <br />New Pump ump Replacement ❑ Pump Repair _ Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method Ci Mud Rotary i Air Rotary Auger C Cable Tool f: Push Point Other <br />Proposed Well Depth ft Excavation in diameter _1 Open Bottom Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter I Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched Steel - Plastic fi Stainless Steel 71 Other <br />Grout Seal Depth ft Neat Cement (94 Ib bagl5-10 gal water) 1 Sand Cement sack mix/7 gal Water <br />C Bentonite (20% solids) L3 Other <br />Grout Placement Method ': Pumped -. Free Fall L' Other :: Retardant / Accelerator (name) <br />PEDESTAL Installed By C Driller _ Pump Contractor C Other <br />C Concrete Pedestal ':Dimensions: Width ft Length ft Thick in 'Christy Box C Stove Pipe <br />PUMP Submersible.: Turbine G Other. HP Pump Set c ft Standing Water Level 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 COMPE ION LAWS. <br />• vn t+. tai. �-7 r.. nn. e... ^r^/// '<. p/,.�.+7-.,-., .,_. <br />SIGNED _ ... TITLE t ,��LTs �, —�r� ,. DATE / al/ <br />-0 �`� I <br />J DEPARTMENT USE ONLY <br />Application Accepted By VC <br />JZ — Date Area (r�� Employee ID# D <br />Grout Inspection By Date tI SPECIAL Well Permit <br />Pump Inspection By L Date l t i7 WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth tt <br />COMMENTS <br />y <br />m <br />D <br />0 <br />M <br />N <br />RECEIVED <br />UC 0 3 2021 <br />N JOAQUIN COUNTY <br />ENVIRONMENTAL <br />ALTH DEPARTMEN1 <br />PE <br />Codes <br />SC Receive <br />Info <br />Check#/ Amount Permit! <br />Cash Remitted et Servic Re uest # Invoice # Well ID# <br />43E'I <br />oYO <br />�S�-477 WE I a2- <br />2 -4 -c) <br />0 -u <br />--'r(6 O / -1-V WELLIPUMPPERMIT <br />