Laserfiche WebLink
I WELLIPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN-Ktt-UNUABLL t'LRMI I <br />❑Monitoring Well(s) # of wells ❑ Soil Boring # of borings s) ❑Geotechnical <br />t ALL <br />LUy U0,5 -/by/ FUR INSPEGI IONS CJCt'IKCb 'I TEAK FKOM DATE ISSUED <br />JOB ADDRESS 7274 E <br />St <br />Rt Hwy 26 <br />CITY/ZIP Stockton,CA 95215 <br />CROSS STREET Alpine <br />Rd <br />APN <br />1 012501 1 PARCEL SIZE. 3 0 LAND USE APPLICATION # <br />OWNER NAME Grace Azevedo PHONE <br />OWNER ADDRESS p-0- Rnx S A q CITY/STATE/ZIP Linden , CA 95236 <br />CONTRACTOR Purviance Drillers, Inc PHONE209-887-3554 <br />PO Box 64 Linden, CA 95236 <br />CONTRACTOR ADDRESS CITY/STATEIZIP <br />SUBCONTRACTOR n / a PHONE <br />SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br />LICENSE XXC-57 ❑ C-61 ❑ D-09 Other NUMBER 377923 EXPIRATION DATE 7/ 31 /23 <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE IDomestic/Private ❑ Irrigation/Agricultural ❑ Industrial F1 Water Quality Monitoring [I Soil Sampling/Characterization <br />((❑ `Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK ❑ New Well Cl Replacement Well [1 Well Alteration/Modification ❑ Other <br />❑Monitoring Well(s) # of wells ❑ Soil Boring # of borings s) ❑Geotechnical <br />Amount Permit/ <br />Remitted ate Service R0 est # Invoice # Well ID# <br />❑ Out -Of -Service Well U Out -Of -Service Well Renewal L Cross -Connection Repair <br />V1ZTEI V Ep <br />❑ New Pump ❑ Pump Replacement_ Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION <br />2 2072 <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary F; Auger ❑ Cable Tool ❑ Push Point n Other SAN d— <br />. <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/G vill$� <br />(Zot# eter <br />NEALTy`DE''PP <br />I-ConductorCasing in diameter / Conductor Casing Depth ft <br />NNTAL <br />Well Casing Diameter in Thickness/Gauge/ASTMSched - Steel ❑ Plastic ❑ Stainless Steel <br />❑ OtherART1yENT <br />Grout Seat Depth ft ❑ Neat Cement (94 /b bagl5-10 gal water) ❑ Sand Cement <br />sack mix/7 gal water <br />L Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By C Driller ❑Pump Contractor G Other <br />❑ Concrete Pedestal []Dimensions: Width ft Length ft Thick <br />n C Christy Box ❑ Stove Pipe <br />PUMP SubmersibleC Turbine ❑ Other HP Pump Set 0 ft Standing Water Level ft <br />Plot Plan Req "rements: 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 />DEPARTMENTUSEONLY U <br />Application Accepted By _ r_Li` Date C / Area I V Employee ID# fill, S <br />Grout Inspection By / Date ❑ SPECIAL Well Permit <br />Pump Inspection By��•�y�,`Tc, Date l I, U WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />7� <br />PE <br />Codes <br />SC Received Check#/ <br />Info By ash <br />Amount Permit/ <br />Remitted ate Service R0 est # Invoice # Well ID# <br />LI <br />J 7 2 '' <br />I <br />I I <br />EHD041-06 10/252021 P.- I ort Nell /Pump Permi: <br />