Laserfiche WebLink
WELLIPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468.3420 <br />NUN-KEFUNDABLE PERMIT www sjgov org/ehd EXPIRES 1 YEAR FROM DATE ISSUES <br />JOB ADDRESS 1 2747 N St Rf- HW)Z AR CrryZP .OdI ,CA 95240 <br />CROSSSTREET TOkaV Colony Rd APN 0631 8025 PARCEL SIZE? 57 - 0 JLAND USE APPLICATION# <br />OWNERNAME Pete G & Emily :: Katzakian Family Trust PHONE <br />OWNERADDRESS 12133 Baker Rd <br />CONTRACTOR Purviance Drillers, INC <br />CONTRACTOR ADDRESS P - 0 - BOX 64 <br />SUBCONTRACTORICONSULTANT <br />CITYISTATE/ZIP Stock ton, CA 95215 <br />PHoNE209-887-3554 <br />CmY/sTATEMPL i nden CA 95236 <br />PHONE <br />SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATEIZIP <br />LICENSE R C-57 C-61 D-09 J Other NUMBER 377923 EXPIRATION DATE 7/31/21 <br />BILLING PARTY: _OWNER ,'l CONTRACTOR a SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: C General Mineral/Coliform Bacteria (4391) Ll DihrornochloroDrODane (4392) rl Ampnin (43931 <br />INTENDED USE L DomesticfPrivate Jrrigation/Agricultural C Industrial Water Quality Monitoring Soil Sampling/CharactednUan <br />C Public Water Sys em <br />If tliiferent from Owner. Wafer System Name Contact Name or Phone Number <br />._ rvew vven ; ; replacement well t: Well MterationlModitication C Other <br />0 Monitoring Well(s) # of wells D Soil Boring(s) ft of borings Geotechnical # or borings <br />D Out -Of -Service Well Li Out-OfServire Well Renewal L Cross -Connection Repair <br />Drilling Method 7� Mud Rotary i Air Rotary G Auger G Cable Tool C Push Point C Other <br />Proposed Well Depth ft Excavation in diameter :] Open Bottom 01 Gravel Pack/Gravel Size in diameter <br />J Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thicknesa/Gauge/ASTM Schad '- Steel 7 Plastic II Stainless Steel U Other <br />Grout Seal Depth ft i_ Neat Cement 194 Ib bagl5-10 gal water) C Sand Cement sack mix/7 gal water <br />L Bentonite (20% solids) ❑ Other <br />Grout Placement Method Pumped Free Fall C Other Retardant I Accelerator (name) <br />PEDESTAL Installed By '— Driller L Pump Contractor C Other <br />C Concrete Pedestal '_Dimensions: Width ft Length ft Thick in ❑ Christy Box I i Stove Plpe <br />Pu MP " Submersibl Turbine C Other HP t­--7Pump Set? a ft Standing Water level 3 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 1 AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />OG RC/ UR ADVANCE NOTICE REQUIRED FOR INSP TtONS . P'!_7AIE f .o, _1_ ffn0, rJ <br />SIGNED l'�— TmE DATE / RiLL? <br />&Ec V N 7 <br />"i' APR <br />Oq QU/ <br />TH p p E O'U, 7'Y <br />ENT <br />DEPARTMENT USE. ONLY <br />Application Accepted B?: Date Date ` I Area Employee I i �l / •_ %'" <br />ID# , , <br />Grout Inspection By A Date 1 SPECIAL Wel) Permit <br />Pump Inspection By .. Date I WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />PE <br />Codes <br />SC Received Check#/ Amount Date permit/ <br />Into Cash Remitted ice Re ue t# Invoice# Well IDS <br />I t I <br />/ q. �Il /. 2, 3'�1 /751 WELL/PUMP PERMIT <br />