Laserfiche WebLink
WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE -STOCKTON CA 95205 -6232 (209) 468-3420 <br />DABLE PERMIT <br />1 YEAR FROM DATE ISSUED <br />JOBADDRESS 18209 E Milton Rd Cr-MPILindlPn CA 95236 <br />CROSS STREET Duncan Rd APN 1 0 51 4 01 1 PARCEL SIZE 10 • 0 LAND USE APPLICATION # <br />OWNERNAIIIE CRM Farms PHONE 209 401 6886 <br />OWNERADDRESS 18501 E Milton Rd CrrY/STATE21P Linden, CA 95236 <br />CONTRACTOR Purviance Drillers, INC PHONE209-887-3554 <br />CONTRACTOR ADDRESS P.O. BOX 64 CITY/STATEIZIPLlnden CA 95236 <br />SUBCONTRACTOR/CONSULTANT <br />LICENSE X C-57 <br />BILLING PARTY: <br />TANT ADDRESS <br />C-61 D-09 <br />:: OWNER <br />PHONE <br />CITY/STATE/ZIP <br />u Other NUMBER 377923 ExpiRATION <br />!''CONTRACTOR SUBCONTRACTORICONSULTANT <br />DOMESTIC WELL SAMPLING: C-: General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) 11 Arsenic (4393) <br />7/31/23 <br />INTENDED USE G Public i atter Sys IrrigationlAgricultural _Industrial G Water Quality Monitoring t: Sail Sampling/Characterization <br />C Public Water System <br />If different from Owner. Water System Name Contact Name or Phone Number <br />u 1%n vv neplacemenr vven ,: Well Alteration/Modification ,! Other <br />D Monitoring Well(s) _ # of wells Soil Borings) of borings Geotechnical <br />D Out -Of -Service Well LI Out -Of -Service Well Renewal -- Cross -Connection Repair <br /># of borings <br />Drilling Method Mud Rotary Air Rotary _ Auger G Cable Tool _: Push Point G Other <br />Proposed Well Depth ft Excavation in diameter C Open Bottom I Gravel Pack/Gravel Size in diame e <br />- Conductor Casing in diameter / Conductor Casing Depth ft Sq N <br />Well Casing Diameter _ in Thlckness/Gauge/ASTM Sched Steel G Plastic I Stainless Steel ; I Other �� <br />Grout Seal Depth ft Neat Cement (94 /b bag/S-10 gal water) D Sand Cement__ sack mi <br />Bentonite (20% solids) J Other <br />Grout Placement Method l Pumped Free Fall I: Other Retardant / Accelerator (name) <br />PEDESTAL Installed By _ Driller _ Pump Contractor ❑ Other <br />Concrete Pedestal ':Dimensions: Width ft Length ft Thick in [: Christy Box Stove Pipe <br />Turbine ' Other HP i <br />_UMP SLbmersibl�x_ i Pump Set Imo( / ft Standing Water Level <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 />m <br />m <br />D <br />0 <br />m <br />N <br />�EC MFNT <br />OR <br />QU/N <br />E MFNOUNTY <br />� R T MENT <br />DEPARTMENT USE ONLY <br />Application Accepted By Z - I _ DateA&T <br />Area `� � Employee ID#Grout Inspection By �% ! Date 1 SPECIAL Well Permit <br />Pump Inspection By Date i WAIVER Received <br />Soil Boring Inspection ByDate Constructed Well Depth ft <br />COMMENTS �yC •/iYldit (' (�J t' IYIG:I (S .f <br />PE <br />Codes <br />SC Received Check#/ <br />I Info Cash <br />Amount <br />Remitted Datq <br />Permitf <br />Service Re uest # Invoice # Well ID# <br />3 <br />b 0V i-5-- <br />f i 7I, r <br />/! /l - f' / �� � WELL [PUMP PERMIT <br />