Laserfiche WebLink
{ WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />NUN-KEFUNDABLE PERMIT WWW.sigoy.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />Jos ADDRESS French r amp Rr9 CITY0PMant-c ca,(.A 95336 <br />CROSS STREET LC)d l] C a D r APN 1 7 71 0 0 4 4 PARCEL SIZE 9- O LAND USE APPLICATION # Q <br />OWNERNAME CaffesP PArmi na PHONE `111- LJ'/'7 7 <br />OWNERADDRESS 6464 Live Oak Rd CIN/STATE/ZIPLOdi,CA 95240 J <br />CONTRACTOR Purviance Drillers, INC PHONE209-887-3554 <br />CONTRACTOR ADDRESS P- O- BOX 64 Clr,/srATE21PLi nden CA 95236 <br />k C-57 <br />PARTY: <br />TANT <br />TANT ADDRESS <br />C-61 7 D-09 <br />OWNER <br />CrTY/STATE21P <br />Other NUMBER 377923 <br />L: CONTRACTOR L; SUBCONTRACTORICONSULTANT <br />PHONE <br />EXPIRATION DATE 7 / 3 1 / 2� <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) -i Dibromochloropropane (4392)l ; Arsenic (4393) <br />NTENDED USE omestidPrivate ! Irrigation/Agricultural : Industrial �i Water Quality Monitoring G Soil Sampling/Characterization <br />Public Water System <br />If different from Ovmer Water System Name Contact Name or Phone Number <br />rvew vven .. meplacement vvell Well Hlreration/Modnication C_ Other <br />Monitoring Well(s) # of wells ! Soil Bodng(s) # of borings Geotechnical # of borings <br />Out -Of -Service Well C Out -Of -Service Well Renewal Cross -Connection Repair <br />New Pump __,Pump Replacement :7 Pump Repair ❑ Raise Well Casino <br />Drilling Method :: Mud Rotary 1 Air Rotary i i Auger = Cable Tool . Push Point Other <br />Proposed Well Depth ft Excavation in diameter Open Bottom fl Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well CaSing Diameter in Thickness/Gauge/ASTM Schad . ' Steel Plastic i Stainless Steel -1 Other <br />Grout Seal Depth ft Neat Cement (94 /b bagl5-10 gal water) ! Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) 7 Other <br />Grout Placement Method :: Pumped i Free Fall C Other Retardant / Accelerator (name) <br />PEDESTAL Installed By = Driller -I Pump Contractor L Other <br />Concrete Pedestal !'Dimensions: Width ft Length It Thick in 1i Christy Box ❑ Stove Pipe <br />PUMP Submersible _- Turbine - ; Other HP Pump Set It Standing Water Level �' �� g <br />I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE 15 <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />t/7 <br />M <br />D <br />O <br />A <br />rn <br />9 <br />DEPARTMENT USE ONLY / <br />Application Accepted By �Z"Z Date o -' r- ! Area ( Employee ID# C� <br />GroutInspection By Date _ i SPECIAL Well Permit <br />Pump Inspection By M Date ��2.1 ] WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />PE <br />Codes <br />SC ReceivedChec�#1 <br />Info <br />Amount <br />Cash Remitted D48 <br />Permit/ <br />Service Re uest # Invoice # Well ID# <br />LI <br />EH043-06 611[/2079 WELL !PUMP PERMIT <br />� LW <br />YMENT <br />-EIVED <br />03 2021 <br />,QUIN COUNTY <br />IONMENTAL <br />DEPARTMENT <br />