WP0042997 - Laserfiche WebLink

Home Browse Search

WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)46$-3420 NON-REFUNDABLE PERMIT www.sigov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED JOBADDRESs 3442 Beecher Rd CIn./zlPStockton,CA 95215 a m D CROSS STREET St RT Hwy 26 APN 089180620 PARCELS .O 1 LAND USE APPLICATION# "1 y m OWNERNAME Don Ghi Q1 i pri PHONE_ N OWNERADDREss 3500 N Beecher Rd OrYISTATEMP Stockton.CA 95215 COWMACTOR Purviance Drillers, INC PHONE209-887-3554 CONTRACTOR ADDRESS P-O. Box 64 CITYISTATE/LPLinden CA 95236 SUBCONTRACTORICONSULTANT PHONE SUBCONTRACTORICONSULTANT ADDRESS CITYISTATE/ZIP LICENSE $C.57 ❑C-61 D D-09 D Other NUMBER 377923 EXPIRATION DATE 7/31/21 BILLING PARTY: D OWNER C CONTRACTOR D SUBCONTRACTORICONSULTANT DOMESTIC WELL SAMPLING:❑General MineraUColiform Bacteria(4391)❑Dibromochloropropane(4392)❑Arsenic(4393) INTENDED USE Itic/Private D IrrigaUon/Agricultural C Industrial D Water Quality Monitoring D Soil Sampling/Characterization L Public Water System If dltTerent from Owner. Water System Name Contact Name or Phone Number TYPE OF WORK ❑New Well C Replacement Well C Well Alteration/Modification D Other Monitoring Well(s) #ofwells C Soil Both g(s) #Ofborings D Geotechnical #of borings Out-Of-Service Well C Out-Of-Service Well Renewal C Cross-Connection Repair New Pump D Pump Replacement Pump Repair ❑Raise Well Casing WELL CONSTRUCTION Drilling Method D Mud Rotary D Air Rotary D Auger O Cable Tool D Push Point D Other Proposed Well Depth ft Excavation in diameter 11 Open Bottom C Gravel Pack/Gravel Slze in diameter D Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter_in Thickness/Gauge/ASTM Sched D Steel C Plastic ❑Stainless Steel D Other Grout Seal Depth ft ❑Neat Cement(94 Ib bag/5.10 gal wafer) D Sand Cement sack mlx/7 gal water O Bentonite(2A solids) D Other Grout Placement Method D Pumped C Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By D Driller C Pump Contractor C Other C Concrete Pedestal DDimenslons:Width ft Length It Thick in C Christy Box D Stove Pipe PUMP ubmersible❑Turbine ❑Other HP l . Pump Set �-' ft Standing Water Level Ift I HEREBY CE TIFY THAT I HAVE-PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. i ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. :l'NCPE tNO irE RFkt IRE'J FOR INT-P— -rte„#$-PL711ri0-rCAIJ.-{2Oc;5-v SIGNED L`'�l( jam,-tom TITLE DATE ------------------- i k� q� F- QUIN� FFgR �N�Y NT '7 DEPARTMENT USE )ONLY Application Accepted By /� Date S / ! Area 1 ^!(' Employee ID# ' 1 Grout inspection By 11. ,' Date 11 SPECIAL WBII Permit Pump Inspection By 8^/rte Date ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS PE SC Received Check#/ Amount Permit/ Codes Info Cash Remitted Date ervlce RequestInvoice# Well ID* 7,2 LJL EHD 43-06 f✓1tf2019 ^ iZS-1 7�)5� WELL/PUMP PERMIT