Laserfiche WebLink
� r <br /> • WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 952115 6232(209)468-3420 <br /> NON-REFUNDABLE PERMIT <br /> www.s' OV.Or lehd EXPIRES 1 YEAR <br /> JOB ADDRESS 2Q241 E Walnut Rd FROM DATE ISSUED <br /> CFTY/ZIP Linden CA 95236 <br /> ICROSSSTREET Wall Rd J m <br /> APN Q911023 PARCEL 91ZRJ z 9 LAND USE APPLICATION# D <br /> OWNER NAME Kathryn Scott <br /> OWNER ADDRESS -12-0 BOX 619 PHONE.( <br /> CONTRACTOR Purviance Drillers INC CITY/STATE21P_Z,indenCA 95236 <br /> CONTRACTOR ADDRESS P.O. BOX 64 PHONE209-887-3554 <br /> CrTY/STATEIZIPLinden CA 95236 <br /> SUBCONTRACTOR/CONSULTANT <br /> PHONE <br /> SUBCONTRACTOWCONSULTANT ADDRESS <br /> CITY/STATE/ZIP <br /> LICENSE k C-57 C-51 - D-09 Other. <br /> NUMBER 377923 EXPIRATION DATE 7/31/23 <br /> BILLING PARTY: i OWNER CONTRACTOR _: SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:L General MinerallColiform Bacteria(4391)_,Dibromochloropropane(4392)L Arsenic(4393) <br /> INTENDED USE pomesUC/Private ::Irrigation/Agricultural71 Industrial Water Quality Monitoring t:Soil SamplinglCharacterization <br /> Public Water System <br /> If different from owner. Water System Name <br /> CcnUct Name or Phone Number <br /> TYPE OF WORK New Well ^_Replacement Well Well Alteration/Modification :Other <br /> MonitoringWell(s) ft Of wells SoilBoring(s) #of borings <br /> "Geotechnical #of bo ngs <br /> Out-Of-Service Well Out-Of-Service Well Renewal �Cross-Connection Repair <br /> New Pum Pum Replacement -Pum Repair <br /> WELL CONSTRUCTION C Raise Well Casing <br /> Drilling Method - Mud Rotary C Air Rotary -i Auger Cable Tool Push Point <br /> Proposed Well Depth. - Other <br /> ft Excavation__in diameter I Open Bottom i Gravel Pack/Gravel Size <br /> Conductor Casing in diameter / Conductor Casing Depthin diameter <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched ft <br /> '-:Steel ;,�,plastic i Stainless Steel :l Other <br /> Grout Seal Depth ft Neat Cement(941b bagIS-10 gal water <br /> Bentonite(20%solids) 7 Other Sand Cement sack maR gal water <br /> Grout Placement Method ;Pumped Free Fall i'Other <br /> Retardant/Accelerator(name) <br /> PEDESTAL Installed By _Driller _J Pump Contractor C Other <br /> Concrete Pedestal :Dimensions:Width ft Length ft Thick <br /> in :i Christy Box Stova Plpe <br /> 1PUM V'Submersible"Turbine -Other <br /> HP > Pump Set i �� ft Standing Water Level i J <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE Ift <br /> N ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> WORKERS COMPENSATION <br /> AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> jNN LAWS. <br /> - <br /> SIGNED . <br /> TITLE DATE_/-/':L/ <br /> �yMFN <br /> N� <br /> Nr <br /> DEPARTMENT USE ONLY <br /> Application Accepted By., —�G Date /S o r <br /> ij <br /> Area // �� / Employee ID# h I <br /> Grout Inspection By ate J SPECIAL WBII Permit <br /> Pump Inspection By , ,)li �; � i mate Z` Z <br /> 1 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth <br /> COMMENTS ft <br /> PE SC Received Check#/ Amount <br /> Codes Info Dat PermIV <br /> Cash Remitted Service Re uest# Invoice# Well ID# <br /> EHD 43-06 6/11/2019 / <br /> /3/53 73/� WELLIPUMPPERhIIT <br />