Laserfiche WebLink
R <br />WELUPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205.5232 (209) 4683420 <br />PIVIV-KEFUNUABLE t'ERMIT WWW.sjgoy.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />JOSADDRESs 3003 N Beecher Rd crry0p Stockton. CA 9521 5 <br />CROSS STREET St Rt H W y 26 APN 0 R 91 1 01 4 PARCEL SIZER 1_ S 3.AND USE APPLICATION # <br />OWNER NAME T & A Solari PHONE <br />OWNERADDRESS P.O BOX 7,68 CrrYISTATE21P L Lnden,CA 95236 <br />CONTRACTOR Purviance Drillers, INC PHoNE209-887-3554 <br />CONTRACTOR ADDRESS P . 0. BOX 64 CITYISTATEMPLinden CA 95236 <br />SUBCONTRACTORICONSULTANT <br />PHONE <br />SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATEIZIP <br />LICENSE k C-57 C-61 C D-09 Other NUMBER 377923 ExPIRATION <br />BILLING PARTY: L OWNER ❑ CONTRACTOR i SUBCONTRACTOR/CONSULTANT <br />7/31/21 <br />DOMESTIC WELL SAMPLING: F. General Mineral/Coliform Bacteria (4391) ?I Dibromochloropropane (4392) C Arsenic (4393) <br />INTENDED USE = Domestic/Private SC Irrigation/Agricultural a Industrial ' ! Water Quality Monitoring ;7 Soil Sampling/Characterization <br />Public Water Syste�7m�` <br />if different from Owner. Water System Name Contact Name or Phone Number <br />TYPE OF WORK �] New Well is Replacement Well Well Aheration/Modification ❑ Other <br />7. Monitoring Weli(s) # of wells _ Soil Boring(s) # of borings Geotechnical # of borings <br />Out -Of -Service Well C Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />New Pump -VPump Replacement ii Pump Repair ❑ Raise Well Casino <br />Drilling Method � Mud Rotary ,] Air Rotary Auger ❑ Cable Tool !, Push Point Other <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel PacWGravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in ThicknesstGauge/ASTM Sched U Steel Plastic '1 Stainless Steel I I Other <br />Grout Seal Depth ft - Neat Cement (941b bag/510 gal water) Sand Cement sack mixR gal water <br />Bentonite (20% solids) ❑ Other <br />Grout Placement Method Pumped Free'Fall C Other ;: Retardant /Accelerator (name) <br />PEDESTAL Installed By —. Driller _ Pump Contractor L Other <br />_: Concrete Pedestal -Dimensions: Width it Length It Thick in ;I Christy Box C Stove Pipe <br />PUMP - Submersibl Turbine Other HPG Pump Set 1�.D ft Standing Water Level i— 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 />e <br />w <br />m <br />D <br />0 <br />A <br />m <br />DEPARTMENT USE ONLY <br />Application Accepted By L Date (L� Area I I �' {: Employee ID# '✓ / 1 <br />Grout Inspection By Date.� -1 SPECIAL Well Permit <br />Pump Inspection By Date 7 WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />PE <br />Codes <br />SC Received <br />Info B <br />Check#! Amount Date Permit/Invoice # Well ID# <br />Cash Remitted ce Re nest # <br />EHO43-0e 6411!2019 <br />WELL/PUMP PERMrr <br />