Laserfiche WebLink
WELL/PUMP PERMIT" <br />SON JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />�.v��-,�cr,nvvyoLc rcRiwl I WWW SjgOV <br />JOB ADDRESS 18800 Frazier RD <br />CROSS STREET Clements Rd APN 065-150-1 1 <br />OWNER NAME Prieto Family Trust & Paul wolf <br />OWNER ADDRESS 2328 Brittany Lane <br />CONTRACTOR Purviance Drillers, INC <br />CONTRACTOR ADDRESS P.O. BOX 64 <br />SUBCONTRACTOR/CONSULTANT <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />na EXPIRES 'I YEAR FROM DATE ISSUED <br />CITY/ZIP Linden, CA 9523 <br />_PARCEL SIZE _LAND USE APPLICATION # <br />PHONE 209-482-6321 <br />CITY/STATE/ZIP Lodi , CA 95242 <br />PHONE 209-887-3554 <br />CITYISTATE/ZIPL i n d e n CA 95236 <br />CITY/STATE/ZIP <br />PHONE <br />LICENSE X C-57 <br />-_ C-61 ❑ D-09 <br />❑ Other <br />NUMBER 377923 <br />EXPIRATION DATE 7/ 31 / 2 3 <br />BILLING PARTY: <br />❑ OWNER <br />❑ CONTRACTOR <br />SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: C- General Mineral/Coliform Bacteria (4391) - Dibromochloropropane (4392) C Arsenic (4393) <br />NTENDED USE Domestic/Private Irrigation/Agricultural Industrial 7 Water Quality Monitoring -! Soil Sampling/Characterization <br />Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />1 YPE OF WORK X New Well IReplacement Well ❑ Well Alteration/Modification ❑ Other <br />Monitoring Well(s) of wells ❑ Soil Boring(s) #ofborings Geotechnical #of borings <br />Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />New Pump Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method X Mud Rotary Air Rotary Auger Cable Tool Push Point ❑ Other <br />Proposed Well Depth lGc;v ft Excavation v?-� in diameter eOpen Bottom ❑ Gravel Pack/Gravel Size in diameter <br />- Conductor Casing AJIt in diameter / Conductor Casing Depth ft <br />Well Casing Diameter ji� in Thickness/Gauge/ASTM Sched •252 (Steel _1 Plastic FI Stainless Steel Other <br />Grout Seal Depth 3(v > — ft ❑ Neat Cement (94 /b bag/5-10 gal water) X Sand Cement /O. 3 sack mix/7 gal water <br />Bentonite (20% solids) ❑ Other <br />Grout Placement Method Pumped �i Free Fall i Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller L Pump Contractor L Other <br />Y Concrete Pedestal Dimensions: Width `J ft LeRf;th(�un ft Thick in Christy Box Stove Pipe <br />PUMP Submersible - Turbine . Other HP Pump Set 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 COMPENSATION LAWS. <br />ANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL. (209) 953-7697 <br />SIGNED TITLE <br />Corporate Secretary DATE 8/4/21 <br />AlRTMENT USE ONLY <br />Application Accepted B Date <br />Grout Inspection By Date tli 2( <br />Pump Inspection By Date <br />Soil Boring InsPectioln By Date <br />COMMENTS 14'I Ic11Z I t.);i u�_ c, r,,, pct i— Su�Lrt r l l v. t AL <br />AreaA�erq E <br />PECIAL Well <br />l WAIVER Rece <br />Constructed Well Depth _ <br />A i (. .�� 5Iar <br />I } Lx/ 1) r, d C Z <br />T <br />M <br />D <br />v <br />v <br />M <br />M <br />in <br />u, <br />I D# A' L1i_" I-0 <br />PE SC Received Check#/ <br />Codes InfoB Cash <br />Amount Permit! CT <br />emitted Date Invoic <br />Service Re est # <br />M <br />T117-)) <br />T <br />EHD 43-06 6/11/2019 ��,� - { -2 vel /7/ /I WELL /PUMP PERMIT <br />