Laserfiche WebLink
IJ <br />1 WELL/PUMP PERMIT <br />SAN.JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE -STOCKTON CA 95205 - (209) 468-3420 <br />tvvty-r-1=r'UNUHt5Lt: rtKmlI GALL <br />JOB ADDRESS 8101 N Jacktone Rd <br />UbJ-fbUl FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />CITY/ZIP Stockton,CA 95215 <br />SIZE 3 5 .14 LAND USE APPLICATION # <br />CROSSSTREET Comstock RD APN 08915013 <br />OWNER NAME Joe Baglieto <br />OWNERADDRESs 301 S Aurora <br />CONTRACTOR Purviance Drillers, Inc <br />PO Box 64 <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR n / a <br />SUBCONTRACTOR ADDRESS <br />LICENSE ��-57 C-61 ❑ D-09 C Other <br />PHONE <br />CITY/STATE/ZIP Stockton, CA 95203 <br />PHONE209-887-3554 <br />CITY/STATE/ZIP L.Inden, CA 95236 <br />PHON <br />CITY/STATE/ZIP <br />NUMBER 3 7 7 9 2 3 EXPIRATION DATE 7/ 31 / 2 3 <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) -: Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE L Domestic/Private Irrigation/Agricultural :3 Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br />Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK <br />New Well ❑ Replacement Well Well Alteration/Modification C Other <br />C MonitoringWells # of wells C Soil Boring(s) s , of borings fAbZ4&Z- O gO GeotechnicalT <br />L Out -Of -Service Well Out -Of -Service Well Renewal ❑ Cross -Connection Repair �V r,' <br />C New Pump Pump Replacement _ Pump Repair L Raise Well Casino -U <br />WELL CONSTRUCTION 1 <br />Drilling Method Mud Rotary l Air Rotary ❑ Auger Cable Tool [I Push Point Ll Other SAN ZOZ� <br />Proposed Well Depth ft Excavation in diameter ij Open Bottom ❑ Gravel Pack/Gra W/1� .q'U,I/N C `ameter <br />C Conductor Casino in diameter 1 Conductor Casing Depth ftLTH DEQ✓fEN0q NT y <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel Plastic ❑ Stainless Steel iI Other 4 <br />RTMS41Z <br />Grout Seal Depth ft L� Neat Cement (94 !b bag/5-90 ga! wafer) Sand Cement sack mW7 gal water <br />C Bentonite (20% solids) :: Other <br />Grout Placement Method Pumped ❑ Free Fall L Other h Retardant / Accelerator (name) <br />PEDESTAL Installed By 1 Driller C Pump Contractor ❑ Other <br />11 Concrete Pedestal ❑Dimensions: Width ft Length ft Thick <br />�in E. Christy Box Stove Pipe <br />PUMP ❑ Submersibl Turbine a Other HP Pump Set 400 ft Standing Water Level ti ft <br />Plot Plan Requirements: Attach,a plot plan with the exact location of water well with respect to the following items: GPS <br />Coordinates, property lines, adjoining properties, water bodies or courses, drainage pattern, roads, existing wells, structures, <br />potential sources of contamination, sewers or private disposal systems. Include distance from two property lines. For Domestic, <br />Agriculture, Industrial well, provide location of any water wells or surface water within 200' radius of proposed well. <br />MININR .`.I '_s IIOi. R :�DI':i\C'E N(YPI('I. REQI IRED F()Rysw:I ('-rioNs _ Pi.i7_ sF. C' uj. (209) 953-7W)- <br />7� ll DEPARTMENT USE ONLY u1 <br />Application Accepted By l�/� C Z-- F � Date Py �Area / / Employee ID# Ft,: to /C <br />Grout Inspection By _ Date II ❑ SPECIAL Well Permit <br />Pump Inspection By " Date (i /) 1 WAIVER R@C61V0d <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS_�UieJ�!t',en <br />T <br />-i <br />m <br />D <br />O <br />n] <br />m <br />En <br />PE <br />Codes <br />Sc Received <br />Info B <br />Check#1 <br />Cash <br />Amount Date <br />Remitted <br />Permit/Invoice # Well ID# <br />Service Request # <br />3� <br />O5O <br />_. <br />47 <br />-, <br />EHD043-05 Nil -5,7021 /i Page I of 2 Well f Pump Permit <br />77LLjjCCJJLL/ 1 �s/l 7s <br />