Laserfiche WebLink
WELUPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 952n5 Jt237 r9Ao1 ArQ_1A11 <br />NUN -REFUNDABLE PERMIT _ WWW.SIQOV.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 7922 E. Ei ght Mita Rd CITY/ZIF&}nrki-nn r CA 95715 <br />CROSS STREET A l p i n es R rl APN 08654004 PARCEL SaE&_;Z_LAND USE APPLICATION # _ <br />OWNER NAME Leland $pi qpl PHONE <br />OWNER ADDRESS 7q 22 F p.i gh j- Mi le Rd CITYISTATE/Z1P qf-nr-kt-nnrra 45215 <br />CONTRACTOR Purviance Drillers INCPHONE209-887-3554 <br />CONTRACTOR ADDRESS P- G- BOX 64 CInISTATEIZIPLi nden CA 95236 <br />TAINT <br />TANT ADDRESS <br />CITYISTATE/ZIP. <br />PHONE <br />LICENSE k C-57 __ C-61 ii D-09 Other NUMBER 377923 EXPIRATION DATE 7 3 1 1 2 1 <br />BILLING PARTY: :] OWNER Cl CONTRACTOR SUBCONTRACTORICONSULTANT <br />DOMESTIC WELL SAMPLING: F General Mineral/Coliform Bacteria (4391) _ DlbromochloroDroDane (4392) fl Arsenic 143f131 <br />INTENDED USE XDomestic/Private Irrigation/Agricultural _: Industrial I Water Quality Monitoring n Soil Sampling/Characterization <br />Public Water System <br />If different from owner Water System Names Contact Name or Phone Number <br />.. !1— vren i. mepmcemeni vveu I; well AReration/Modification .: Other <br />I Monitoring Well(s) # of wells C Soil Boring(s) # of borings ,Geotechnical # of borings <br />Out -Of -Service Well G Out -Of -Service Well Renewal 1 Cross -Connection Repair <br />"I New Pump X Pump Replacement G Pump Repair C Raise Well Casino <br />Drilling Method Mud Rotary Air Rotary a Auger a Cable Tool . Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter ; I Open Bottom r I Gravel Pack/Gravel Size in diameter <br />7 Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched Steel Plastic G Stainless Steel ❑ Other <br />Grout Seal Depth ft Neat Cement (94 Ib bag/5-10 gal water) �i Sand Cement Sack mix/7 gal Water <br />J Bentonite (20% solids) ❑ Other <br />Grout Placement Method Pumped Free Fall C Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller _ Pump Contractor U Other <br />Concrete Pedestal --Dimensions: Width ft Length ft Thick in Christy BOX C Stove Pipe <br />PUMP Submersible❑Turbine Other HP Pump Sel�—_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 />//�j�{. �/.... .... 3"L.L".�i.i.0 Cilii•..L (L1T1a1 <br />SIGN. .GriE(/L/�f-�.C. TRLE-�a�/��/ <br />DATE ZI <br />/DEPARTMENT US ONLY 1 <br />Application Accepted By C Date Ci �� �� Area �i C� Employee ID# D/L <br />Grout Inspection By Dace ❑ SPECIAL Well Permit <br />Pump Inspection By Date LII . t l .11 t WAIVER Received <br />Soil Boring Inspection By 1 Date `T Constructed Well Depth ft <br />COMMENTS <br />M <br />D <br />0 <br />If6��,4N� �NTy <br />MFfv)� <br />PE <br />Codes <br />SC Received Check#1 Amount pe�IV <br />Info B Cash Remitted Date •Ce R uest # Invoice # Well ID# <br />VIIJFHA <br />A'lJIF <br />e/1 r�no if .! <br />WELL /PUMP PERMR <br />