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WP0042192
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4200/4300 - Liquid Waste/Water Well Permits
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WP0042192
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Entry Properties
Last modified
12/13/2021 9:50:49 AM
Creation date
12/13/2021 9:18:07 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
WP0042192
PE
4381
STREET_NUMBER
10903
Direction
E
STREET_NAME
ADA
STREET_TYPE
AVE
City
STOCKTON
Zip
95215-
APN
10314005
ENTERED_DATE
6/23/2021 12:00:00 AM
SITE_LOCATION
10903 E ADA AVE
P_LOCATION
99
P_DISTRICT
004
QC Status
Approved
Scanner
SJGOV\tsok
Supplemental fields
CYEAR
2021
Tags
EHD - Public
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SAN JOApUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT PERMIT <br />1868 EAST HAZELTON AVENUE - STocKTON CA 95205 X232 (209) 46$3420 <br />' <br />NON-REFUNDABLE PERMIT WWW,$OV.Or /ehd <br />EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 1 n q (1 Z F a r7 a a <br />ue C"ZIPSt QckF C Oc c <br />CROSS STREET P a t t n n A Vp APN fl r <br />�4� � 4 �8� PARCEL SIZE _LAND USE PLICATION # <br />OWNER NAME LaVc rna C;a rAnar •J �� <br />PHONE <br />OWNER ADDRESS 1(] q Q3 F` T»Cja A V 8 <br />CITY/$TATEIZIPStnr•kt <br />CONTRACTOR Purviance Drillers, INC <br />PHONE209-887-3554 <br />CONTRACTOR ADDRESS P.O. BOX 64 <br />CITY/STATE/ZIPLinden CA 95236 <br />SUBCONTRACTOWCONSULTANT <br />PHONE <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />CITY/STATE/ZIP <br />LICENSE �t C-57 C-61 i D-09 Other377923 <br />NUMBEREXPIRATION DATE 7/31 / 21 <br />BILLING PARTY: OWNER CONTRACTOR c SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: C General Mineral/Coliform Bacteria (4391) - Dibromochloropropane (4392)1- Arsenic (4393) <br />INTENDED USE DomesticlPrivate I i n/ <br />mC <br />ga to Agricultural I , Industrial = Water Quality Monitoring <br />Public Water System I' Soil Sampling/Characterization <br />IfdiBerent fmm 0, Water System Name <br />ContaU Name w Phone Number <br />TYPE OF WORK New Well f: Replacement Well <br />Monitoring Well(s) # of wells <br />Out -Of -Service Well <br />New P, <br />Well Alteration/Modification C: Other <br />:- SoiiBoring(s) #ofborings <br />:I Geotechnical #of borings <br />L <br />Out -Of -Service Well Renewal -1 Cross -Connection Repair <br />G Pump Repair _ C Raise Wwll r,—i— <br />Drilling Method _: Mud Rotary `i Air Rotary _ Auger = Cable Tool it Push Point Other <br />Proposed Well Depth ft Excavation <br />in diameter 0 Open Bottom ❑Gravel Pack/Gravel Size <br />Conductor Casing in diameter /Conductor Casing Depth n diameter <br />Well Casing Diameter in Thickness/Gauge/ASTM Schad ft <br />_ <br />7 Steel C Plastic ; : Stainless Seel , I Other <br />Grout Seal Depth ft __Neat Cement (94 /b ba9/Sa! water) 9 ) Sand Cement sack mix/ 7 gal water <br />G BentonRe(20% solids) Li Other <br />Grout Placement Method :: Pumped . Free Fall L Other <br />Retardant / Accelerator (name) <br />PEDESTAL tailed By Driller Pump Contractor L ��eh <br />Concrete Pedestal '.Dimensions: Width ft ft Thick <br />in Christy Box : ]Stove Pipe <br />(PUMP > Submersible: Turbind OtherHP _ <br />Pump Set 1�ng Water Level ft <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE INACCORDANCEWITH 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 IAM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />'7f JANCE NOTICE .moi'>•.icocF. r, c, r <br />SIGNEu� !/./Zi/ iZiy�L .. . .'(209) _ <br />TITLE / <br />DATE � <br />DEPARTMENT USE ONLY <br />Application Accepted By ��1�� <br />Date Area Jn! { <br />Grout Inspection By Em <br />ate ployee ID# <br />' SPECIAL Well Permit <br />Soil Bo <br />Pump Inspection By ,,1 ate <br />WAIVER Received <br />ring Inspection By Date <br />COMMENTS �_ Constructed Well Depth ft <br />U <br />D <br />0 <br />0 <br />m <br />y <br />IN 23 ?021 <br />4 Qu,tv <br />Dip EIVTgANTy <br />A�TM�NT <br />
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