Laserfiche WebLink
WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 -6232 f9nQ1 AAA_1d1t <br />1 <br />JOB ADDRESS 1630", Baker RD CITY/ZIP Linden.CA 95236 <br />CROSS STREET fly l I, prq APN _ 0 91 0 9 0 31 PARCEL SIZE3 7 _ 7 LAND USE APPLICATION # <br />OWNERNAME Robert FrPPman <br />PHONE <br />OWNERADDRESS 10323 Baker Rd CRY/STATEMP T,inr3en,CA 95236 <br />CONTRACTOR Purviance Drillers, INC PHONE209-887-3554 <br />CONTRACTOR ADDRESS P - 0. Box 64 Cm./STATE21PLlnden CA 95236 <br />SUBCONTRACTOR/CONSULTANT <br />PHONE <br />SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATEIZIP <br />LICENSE R C-57 i; C-61 :'. D-09 ! Other NUMBER 377923 ExPIRATION DATE 7/31/23 <br />BILLING PARTY: ❑ OWNER ] CONTRACTOR J SUBCONTRACTORICONSULTANT <br />UUMh5TIC VVELL SAMPLING: G General Mineral/Coliform Bacteria (4391) _i Dibromochlornornnane 14392M: Arsenic rn'40v1 <br />NTENDED USE Domestic/Private 11 Irrigation/Agricultural l] Industrial _ Water Quality Monitoring [ 1 Soil Samp(ing/Characterization <br />Public Water System <br />If different from Owner. Water System Name Contact Name or Phone Number <br />rYPF r)r V1—V M. -1A1 I <br />-- --- ---- -- ..-r-.-�- „ .,oar—alauummoumcauon it umer <br />0Monitoring Weli(s) #ofwells SoilBoring(s) Mofborh9s Geotechnical Morbodngs <br />C Out -Of -Service Well �] Out -Of -Service Well Renewal U Cross -Connection Repair <br />C: New Pump Pump Replacement Pum Re air i:.'ylci C Raise Well Casinq <br />WELL CONSTRUCTION <br />Drilling Method '_ Mud Rotary Air Rotary L, Auger Cable Tool C Push Point 1� Other <br />Proposed Well Depth ft Excavation in diameter U Open Bottom U Gravel Pack/Gravel Size in diameter <br />C Conductor Casing in diameter / Conductor Casing Depth g <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Schad Steel L� Plastic ❑ Stainless Steel U Other <br />Grout Seal Depth it Neat Cement (94 /b bagl5-10 gal water) _ Sand Cement sack mixf7 gal water <br />Bentonite (20% solids) J Other <br />Grout Placement Method -: Pumped Free Fall G Other C Retardant / Accelerator (name) <br />PEDESTAL Installed By _ Driller . Pump Contractor G Other <br />Concrete Pedestal CDlmenslons: Width ft Length It Thick to it Christy Box I7 Stove Pipe <br />Submersible)XTurbine G Other HP;2 2 _ Pump Set O it Standing Water Level / SC 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 />WORKERS COMPENSATION LAWS. <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br />DEPARTMENT USE ONLY <br />Application Accepted By D <br />/` ` C; I Area C� <br />Date Employee ID# <br />Grout Inspection By Date I I SPECIAL Well Permit <br />Pump Inspection By Date l� ❑ WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />PE SC Received Check#J Ann Permit/ <br />Codes Info ash RtDle —,Service Request # Invoice # Well ID# <br />L3�� J r <br />EH043-06 6/112019 _ <br />'^z LS _��� WEU (PUMP PERMIT <br />4y/L, <br />CF1 �� T <br />D <br />29202, <br />�J/N Co <br />04R �NT <br />