Laserfiche WebLink
i WELL/PUMP PERMIT <br />SAN.JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209) 468-3420 <br />IVUN-KEFU <br />JOB ADDRESS <br />NDABLE VERMIT GALL 1ZUy) 140.5-1 OU / FUR IN5FLc I IUNb r-ArlMr-0 I T tAK hKUM UA I t IJSULU <br />40ol Duncan Rd CITY/ZIP Linden, CA <br />Hwy 26 APN 10509009 PARCEL SIZE f 1 LAND USE APPLICATION # <br />Galvin/Podesta Properties PHONE 209-351-0664 <br />CROSS STREET <br />OWNER NAME <br />OWNER ADDRESS 5432 Giovanni Ct crn,/STATEIZIP Linden, CA 95236 <br />CONTRACTOR Purviance Drillers, Inc <br />PO Box 64 <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR n/ a <br />SUBCONTRACTOR ADDRESS <br />LICENSE )QXC-57 C C-61 ❑ D-09 ❑ Other <br />PHONE209-887-3554 <br />CITY/STATE2IP Linden, CA 95236 <br />CITY/STATEIZIP <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 U Domestic/Private IrrigationlAgricultural ❑ Industrial ❑ Water Quality Monitoring D Soil Sampling/Characterization <br />0 Public Water System <br />If different from Owner. Water System Name Contact Name or Phone Number <br />TYPE OF WORK 0 New Well ❑ Replacement Well ❑ Well AlterationlModification 0 Other <br />❑ Monitoring Well(s) # of wells 0 Soil Boring(s) r of borings 0 Geotechnical <br />0 Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />❑ New Pump ❑ Pumo Replacement 1YPumD Repair �T/r'r'� ❑ Raise Well Casino <br />WELL CONSTRUCTION I I 'jcp <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other 84/1/ O w <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Grave N�'U/ diameter <br />Conductor Casing in diameter I Conductor Casing Depth ft C H ,pl'FNp7%EN�irT�Nry <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth ft C Neat Cement (94 lb bag/510 gal water) D Sand Cement sack mixf7 gal wa er <br />❑ Bentonite (20% solids) 0 Other <br />Grout Placement Method 0 Pumped ❑ Free Fall ❑ Other ❑ Retardant I Accelerator (name) <br />PEDESTAL Installed By 'u Driller ❑ Pump Contractor D Other <br />1 Concrete Pedestal ❑Dimensions: Width ft Length ft Thick <br />�in ❑ Christy Box ❑ Stove Pipe <br />PUMP ❑ SubmersibieyTurbine ❑ Other HP Pump Set ft Standing Water Level 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 coarses, 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 />j�j DEPARTMENT #USE ONLY <br />Application Accepted By G'"o � Date <br />Grout Inspection By Date <br />Pump Inspection By_ IL/ ( Date L� <br />Soil Boring Inspection By Date <br />COMMENTS <br />Area ! �% �� Employee ID# / r <br />u SPECIAL Well Permit <br />D WAIVER Received <br />Constructed Well Depth <br />ft <br />T <br />m <br />D <br />O <br />0 <br />M <br />Lo <br />PE SC I Received Checktf <br />Codes Info B Cash <br />Amount <br />PermItf <br />Date Invoice # Well ID -1 <br />Service Re uest# <br />3� Ji <br />j7it�ted <br />Z WP004 3S4 a i <br />EhDCL_-.^.0 In;?:,,2p2l/I � Pa__� I cf2 <br />�� I /� � Well I Punp Perni; <br />'7�; 7SS <br />