Laserfiche WebLink
S <br />I WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE -STOCKTON CA 95205 - (209) 468-3420 <br />I1AUIN-Mtf-UNUA13LE I-'ERMIT GALL (ZU9) 553-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOBADDREss 2353 HAll Ave clTympStockton, CA 95205 <br />CROSS STREET Mariposa Rd APN 17302031 PARCEL SIZE • 4 4 LAND USEGAPP CATIION # C <br />OWNER NAME J n1Ce Anderson PHONE -J J\\'�\ <br />OWNERADDRESS 2353 Hall Ave CITYISTATEIZIP Stockton, CA 95205 <br />CONTRACTOR Purviance Drillers INC PHONE 209 887 3554 <br />CONTRACTOR ADDRESS P.O. BOX 64 CITY/STATvzIP Linden, CA 95236 <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE XC -57 C-61 11 D-09 E Other_ <br />PHONE <br />CITYISTATEIZIP <br />NUMBER 377923 EXPIRATION DATE 7/ 31 / 2 3 <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE XDomesticlPrivate � Irrlgatien/Agricultural I i Industrial -1 Water Quality Monitoring i] Soil Sampling/Characterization <br />L; Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />IYPEOF WORK Cl New Well i I Replacement Well fl Well Alteration/Modification l", Other <br />of borings of rin s <br />Monitoring Well(s) # of wells i i Soil Boring(s) Il Geotechnical �'q^g <br />it Out -Of -Service Well 'i Out -Of -Service Well Renewal F Cross -Connection Repair �Q A YAq <br />].New Pump`�tPump Replacement i Pump Repair I I Raise Well Casing - 4-1 , <br />WELL CONSTRUCTION <br />Drilling Method Mud Rotary '1 Air Rotary fl Auger ❑ Cable Tool _ Push Point i Other <br />Proposed Well Depth ft Excavation in diameter Open Bottom ri Gravel Pack/Gravel S12M in Ir <br />i 1 Conductor Casing in diameter I Conductor Casing Depth ft ENV AQUI <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched 7, Steel i I Plastic I"1 Stainless Steel y� /RONCO <br />Grout Seal Depth ft 7 Neat Cement (94 lb bag/5-10 gal water) t, Sand Cement--,--- Sac ate <br />Bentonite (20% solids) 1 Other <br />Grout Placement Method ! i Pumped r7l Free Fall Other F Retardant / Accelerator (name) <br />`PEDESTAL Installed By -! Driller ! Pump Contractor 1 Other <br />i Concrete Pedestal .Dimensions: Width ft Length ft Thick <br />lin Cl Christy Box fI Stove Pipe <br />PUMP IXSubmersible:l Turbine F Other HP i I d" Pump Set { `l I ft Standing Water Level 1 t?V/_ 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, pro -Ode location of any water wells or surface water within 200' radius of proposed well. <br />DEPARTMENT USE ONLY <br />I / r CJ <br />Application Accepted By� `— �� Date ba Area ► / % / Employee ID# <br />Grout Inspection By Date qq ❑ SPECIAL Well Permit <br />Pump Inspection By Date W C WAIVER Received <br />Soil Boring Inspection By _ Date Constructed Well Depth ft <br />COMMENTS _�e 'S .4(- <br />T <br />M <br />D <br />0 <br />0 <br />z <br />M <br />y <br />PE Sc Received <br />Codes Info By <br />Check#I <br />Cash <br />Amount Dat Permit/ Invoice # Well ID# <br />Remitted Service Re uest# <br />3r e <br />' .f 2Z 'n., <br />E13D043-06 04r07i2022 <br />�� /) � Pada t oR Well; Pomp Pennir <br />