Laserfiche WebLink
1 WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN-KEFUNDABLE FERMIT L;ALLGU`J UbS-/bU/ FOR INSPECTIONS t7.FIKt5 'I YEAR FROM DATE ISSUED <br />JOB ADDRESS 20550 E Kettleman Lane CITY/ZIP Lodi, CA 95236 <br />CROSS STREET clements Rd AP�5318014 <br />OWNER NAME Shawn Wentzel <br />OWNER ADDRESS 20550 E Kettleman Ln <br />CONTRACTOR Purviance Drillers <br />PO Box 64 <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR n / a <br />SIZE 80,4 LAND USE APPLICATION # <br />CITY/STATE/ZIP Lodi, CA 95240 <br />Inc PHONE209-887-3554 <br />CrrY/STATEIZIP Linden, CA 95236 <br />SUBCONTRACTOR ADDRESS <br />LICENSE )XC -57 ❑ C-61 ❑ D-09 ❑ Other <br />PHONE <br />CITY/STATE/ZIP <br />NUMBER 3 7 7 9 2 3 EXPIRATION DATE 7/ 31 / 2 3 <br />DOMESTIC WELL SAMPLING: i : General Mineral/Coliform Bacteria (4391) - Dibromochloropropane (4392).; Arsenic (4393) <br />NTENDED USE ❑ Domestic/Private )Orrigation/Agricultural 0 Industrial 0 Water Quality Monitoring ❑ Soil SamplinglCharacterization <br />❑ Public Water System <br />if different from Owner. Water System Name Contact Name or Phone Number <br />TYPE OF WORK ❑ New Well 0 Replacement Well ❑ Well Alteration/Modification 0 Other <br />❑ Monitoring Well(s) # of wells 0 Soil Boring(s) # of borings ❑ Geotechnical # of borings <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />Drilling Method ❑ Mud Rotary 0 Air Rotary ❑ Auger 0 Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom 0 Gravel Pack/Gravel Size in diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic 0 Stainless Steel D Other <br />Grout Seal Depth ft ❑ Neat Cement (94 Ib bag/5-10 gal water) 0 Sand Cement sack mix17 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped 0 Free Fall 0 Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor 0 Other <br />❑ Concrete Pedestal ❑Dimensions: Width ft Length ft Thick <br />n ❑ Christy Box C Stove Pipe <br />Pump 0 SubmersibleX turbine ❑ Other HP IaS- Pump Set O 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 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 />DEPARTMENT USE ONLY <br />Application Accepted By �_i� �� Date ' d cl' o <br />Grout Inspection By / Date <br />Pump Inspection By l �� �.,'� Date ✓l �� �� <br />Soil Boring In pection By Date_ <br />COMMENTS _ JJe l) l f;- t iVJ F D <br />n <br />Area / � Employee ID# Fl�j ilk <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth ft <br />te.s 6F we 11. <br />PE Sc Received Check#/ Amount <br />Info B Cash Remitted Date <br />Permit/Codes <br />Service Request # Invoice # Well ID# <br />L1344LI s <br />3 <br />EHD043-06 10l2512021 / � Pasc 1 of? Well /Pump Permit <br />�ffwIJ'l Cl�r(J� i <br />