Laserfiche WebLink
*4 <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE -STOCKTON CA 95205 -6232 (209) 4663420 <br />[Mull <br />FROM DATE <br />JOBADDRESS 17510 N Tretheway Rd CITY/ZIP Lodi,Ca 95240 <br />CROSSSTREET Harmony Grove Ln APNQ5118040 PARCEL SIZE2. 78 LAND USE APPLICATION# <br />OWNER NAME Dave Payne PHONE <br />OWNERADDRESS 11600 E. Harmony Grove Ln CITY/STATPJZIPLockeford, CA 95237 <br />CONTRACTOR Purviance Drillers, INC PHDNE209-887-3554 <br />CONTRACTOR ADDRESS P.O. BOX 64 CITY/STATE21PL i nd en CA 9 5 2 3 6 <br />SUBCONTRACTORICONSULTANT <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />LICENSE $ C-57 C-61 _ D-09 <br />BILLING PARTY: --'.. OWNER <br />CrTY/STATE/ZIP <br />Other NUMBER 377923 <br />C CONTRACTOR ['. SUBCONTRACTORICONSULTANT <br />PHONE <br />EXPIRATION DATE 7/31/23 <br />DOMESTIC WELL SAMPLING: G General Mineral/Coliform Bacteria (4391) i i Dibromochiompropane (4392) 11 Arsenic (4393) <br />'NTENDED USE omestirJPrivate '7 Irrigation/Agricultural 17 Industrial D Water Quality Monitoring C Soil Sampling/Characterization <br />Public Water System <br />If ddferent from Owner Water System Name Contact Name or Phone Number <br />rc yr nvrcn _ ivew vven L replacement Well ;; Well AlteratiONMOdification "1 Other <br />C Monitoring Weil(s) # of wells D Soil Bonng(s) # of borings J Geotechnical # of borings <br />D Out -Of -Service Well J Out-OfService Well Renewal Cross -Connection Repair <br />New Pump Pump Replacement D Pump Repair Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method :; Mud Rotary :i Air Rotary ' Auger _" Cable Tool Push Point �. Other <br />Proposed Well Depth ft Excavation in diameter n Open Bottom Li Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched ! : Steel .: Plastic 11 Stainless Steel J Other <br />Grout Seal Depth ft :: Neat Cement (94 Ib bag/5-10 gal wafer) Sand Cement sack mix/7 gal water <br />L Bentonite (20% solids) C Other <br />Grout Placement Method Pumped 't Free Fall J Other Retardant / Accelerator (name) <br />PEDESTAL installed By i Driller C Pump Contractor L Other <br />C Concrete Pedestal -Dimensions: Width ft Length ft Thick in C Christy Box [, Stove Pipe <br />PUMP � Submersible L' Turbine - Other HP Pump Set ��(n it Standing Water Level ��- ft <br />1 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 />DEPARTMENT USE ONLY [►� <br />Application Accepted By _ 1✓� Date f l 6 �I I Area 'I hlci Employee ID# / JC <br />Grout Inspection By Date SPECIAL Well Permit <br />Pump Inspection By 1 % ni ," S t D �. tip +"'� + Date _ I Z / t �! zo � i F1 WAIVER Received <br />Soil Boring Inspection By _ Date Constructed Well Depth ft <br />COMMENTS <br />to <br />RECEIVED <br />NOV 17 2021 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />PE <br />Codes <br />SC Rpcelyed Check#/ Amount PermtU <br />Info Cash Remitted Date Service Re uest # Invoice # Well ID# <br />3NI <br />S" <br />I L - 4F- T � It (10 _` _t�y> 1- 0 / (- ( 110 <br />i _ I WELL (PUMP PERMIT <br />