Laserfiche WebLink
I WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE -STOCKTON CA 95205 - (209) 468-3420 <br />rvnlocC A \f tonna nA-rc ICcl lr-n <br />NON-REFUNDABLE PERMIT GALL ZUU) U0,5-1OuI t -UK INOrM,I1v1VJ ••-�- - - - <br />16255 E St Rt Hwv 26 CITY/ZIP Linden CA 95236 <br />JOB ADDRESS <br />CROSS STREET <br />OWNER NAME <br />Archerdale Rd <br />V & A Lagorio <br />APN 0 91 1 0029 PARCEL SIZE2 0- 3 5 LAND USE APPLICATION # <br />OWNERADDRESS 14625 E Comstock Rd <br />CONTRACTOR Purviance Drillers, Inc <br />PO Box 64 <br />(CONTRACTOR ADDRESS <br />SUBCONTRACTOR <br />n/a <br />!SUBCONTRACTOR ADDRESS <br />(LICENSE )Q. �C-57 ❑ C-61 ❑ D-09 ❑ Other <br />CITYISTATEIZIP Linden,CA 95236 <br />PHONF209-887-3554 <br />CITYISTATE/ZIP Linden, CA 95236 <br />CITY/STATEIZIP <br />NUMBER 377923 EXPIRATION DATE 7/ 31 / 2 3 <br />DOMESTIC WFI I SAMPLING: General MineraUColiform Bacteria (4391) Dibromochioropropane (4392) -Arsenic (4393) <br />INTENDED USE ❑ Domestic/Private Irrigation/Agricultural Industrial ❑ Water Quality Monitoring C Soil Sampling/Characterization <br />C Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK ❑ New Well Replacement Well [I Well Alteration/Modification ❑ Uther <br />Monitoring Well(s) # of wells ❑ Soil Borings) #of borings ❑ Geotechnical IF rings <br />L]n <br />[i Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair REn�E ENT <br />E, New Pump ❑ Pump Replacement Pump Repair �jC' nrC j C Raise Well Casing 1. F11 /[- <br />• L <br />WELL CONSTRUCTION <br />Drilling Method C Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool a Push Point F Other p n 1 nn— <br />Proposed Well Depth ft Excavation in diameter C Open Bottom ❑ Gravel Pack/Gravel In - ter <br />:• Conductor Casing in diameter / Conductor Casing Depth ft EN " UIN COUNT! <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel .14ff Qty ME <br />Grout Seal Depth ft ❑ Neat Cement (94 Ib bag/5-10 gal water) 7 Sand Cement sac ' <br />ow <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method U Pumped ❑ Free Fall ❑ Other C Retardant / Accelerator (name) <br />PEDESTAL Installed By -7 Driller ❑ Pump Contractor _ Other <br />U Concrete Pedestal Ll Dimensions: Width ft Length ft Thick <br />in ❑ Christy Box C Stove Pipe <br />PUMP D Submersiblel5k"Turbine Other HP �_ Pump Set- ft Standing Water LevelttL ft <br />Plot Plan Requirements: Attach .a plot plan with the exact location of water well with respect to the following items: (SPS <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 />T <br />m <br />D <br />0 <br />0 <br />X <br />Cn <br />w <br />DEPARTMENT USE NLY <br />Date ZZ <br />Area � � Employee ID# <br />Application Accepted By _____ <br />Permit/ Invoice # Well ID# <br />Service Re uest# <br />050 <br />Grout Inspection By <br />Date \ <br />L-1 SPECIAL Well Permit <br />WAIVER Received <br />Pump Inspection By _:,L' <br />Date UG <br />❑ <br />Soil Boring Inspection By <br />Date <br />Constructed Well Depth <br />ft II <br />COMMENTS <br />PE SC Received <br />Codes Info By <br />Check#/ <br />Cash <br />Amount Date <br />Remitted <br />Permit/ Invoice # Well ID# <br />Service Re uest# <br />050 <br />I'2 <br />00 H 3f <br />El"43-06 10;3;i'_0'I Page 1 ort Well / Pump Permit <br />