Laserfiche WebLink
t <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232 (209)468-3420 <br /> NON-REFUNDABLE PERMIT WWW.sjqov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> Jos ADDRESS 18110 Von Glahn Ave cIIYIZiP Escalon,CA 95320 m <br /> CROSS STREET St Rt Hwy 1 2 0 APN 24508053 PARCEL SIZE 4 9.5 1AND USE APPLICATION# D <br /> \� O <br /> OWNERNAME AngQjQ Sta rnerQ v�P q-R) a\ �',� PHONE -\� 066 a` y <br /> OWNERADDRESS 18110 VOn G lahn Ave CITYISTATFJZIP Escalon,CA 95320 <br /> CONTRACTOR Purviance Drillers, INC PHOIE209-887-3554 <br /> CONTRACTOR ADDRESS P-0. Box 64 CITYISTATEJZIPLinden CA 95236 <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITYISTATEIZIP <br /> LICENSE X C-57 C-61 _1 D-09 [:Other NUMBER 377923 ExPIRATION DATE 7/31/23 <br /> BILLING PARTY: , OWNER n CONTRACTOR -1 SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:1:General MineraVC01iforrn Bacteria(4391) ;Dibromochloropropane(4392)C Arsenic(4393) <br /> ��"fd�ifferentfmmc�mer. � <br /> e L Irrigation/Agricultural ;Industrial Water Quality Monitoring i.l Soil Sampling/Characterization <br /> stem <br /> ner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK D New Well C Replacement Well Well Alteration/Modification 7,Other <br /> ❑Monitoring Well(s) #of wells Soil Borings) #ofborings 0 Geotechnical Nor borings <br /> D Out-Of-Service Well _Out-Of-Service Well Renewal a Cross-Connection Repair <br /> ❑New Pum *ump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary ;.Auger ;Cable Tool iPush Point _ Other <br /> Proposed Well Depth ft Excavation in diameter L Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter 1 Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad i':Steel L Plastic Stainless Steel ❑Other <br /> Grout Seal Depth ft -Neat Cement(94 Ib bag/5-10 gal water) Sand Cement sack mix17 gal water <br /> Bentonite(20%solids) L'Other <br /> Grout Placement Method _ Pumped L�Free Fall ❑Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller -Pump Contractor L Other <br /> C Concrete Pedestal--'.Dimensions:Width ft Lengthft Thick in Christy Box r Stove Pipe <br /> PUMP Submersible:-,Turbine i;Other HP Pump Set ft Standing Water Level 2-5-ft <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. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> C'VANCE NOTICE REQUIRt_D FOR ^A1..t.. "^^ <br /> SIGNED TITLEDATE <br /> I Ll I <br /> T E� t <br /> - P MENT <br /> a EIVED <br /> 4 2021 <br /> JOA( IN COUNTY <br /> U R MENTAL <br /> PARTMENI[ <br /> ------------- <br /> DEPARTMENT USE ONLY <br /> A <br /> Application Accepted By c�_'� - L rDate '7 ?/✓ Area <br /> -J) �C Employee ID# `t <br /> Grout Inspecf on By Date Z i 1 SPECIAL Well Permit <br /> Pump Inspection By Date 11 WAIVER Received <br /> Soil Boring/inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received C eck#1 Amount Permit! <br /> Codes Info Remitted Pa Service rm uest# Invoice# Well ID# <br /> EHD 43-06 8!71/2019 *kLhP/^ <br /> 2,;? <br /> n^ �- 2 <br /> (f�J( L G C� J UMP PERMIT <br />