Laserfiche WebLink
` WELLIPUMP PERMIT <br />SAN.JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209) 468-3420 <br />NUN-KEFUNDABLE t'ERMIT GALL ZUy) y53-76ti! FOR INSPECTIONS LArIKtS I TEAK PKUM UA i E ISSUED <br />JOB ADDRESS 20389 Walnut DR crry/ZIP Linden,CA 95236 <br />CROSS STREET <br />OWNER NAME <br />Wall Rd <br />Eilers Ranch <br />OWNER ADDRESS P.O. Box 1048 <br />APN 09131022 PARCEL SIZE 19 . 6 MND USE APPLICATION �. <br />LLC PHONE <br />CONTRACTOR Pu.rvia.nce Drillers, Inc <br />PO Box 64 <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR n/ a <br />!SUBCONTRACTOR ADDRESS <br />(LICENSE X.X -57 ❑ C-61 D D-09 it Other <br />Crrr1STATE/ZIPLinden, CA 95236 <br />PHONE209-887-3554 <br />CITY/STATE/ZIP Linden, CA 95236 <br />CITY/STATE/ZIP <br />NUMBER 377923 EXPIRATIONDATE 7/31 /23 <br />DOMESTIC WELL SAMPLING: _ General Mineral/Colifomt Bacteria (4391) Dibromochloropropane (4392) = Arsenic (4393) <br />INTENDED USE�DomestictPrivate ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br />El Public Water System <br />11 different from Owner. Water System Name Contact Name or Phone Number <br />TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br />❑ Monitoring Wells) # of wells ❑ Soil Boring(s) # of borings ❑ Geotechnical V of borings <br />❑ Out -Of -Service Well ❑ Out -O' -Service Well Renewal ❑ Cross -Connection Repair ' <br />❑ New Pump )(Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method = Mud Rotary Air Rotary ❑ Auger G Cable Tool r? Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/4 <br />I In diameter <br />C Conductor Casing in diameter / Conductor Casing Depth ft p <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched D Steel ❑ Plastic ❑ StainlessR(E C:BVrE <br />Grout Seat Depth ft 7 Neat Cement (94 lb bagl5-10 gal water) ❑ Sand Cement sack mlx/7 gal water <br />Bentonite (20% solids) ❑ Other AUG Ir 0 3 222 <br />Grout Placement Method D Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By D Driller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal ❑Dimensions: Width ft Length ftThick �=�W QF=PA oTn4EnIT <br />in 13 Christy Box 0 Stove Pipe <br />PUMP Submersible❑ Turbine D Other HP Pump Set \" 1 l I ft Standing Water Level <br />Plot Plan Re uirements: Attach,a plot plan with the exact location of water well with respect to the following items: CPS <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�� L' Date �S' 3 a Area Gcf Employee ID# t rel n k <br />Grout Inspection By I Date ❑ SPECIAL Well Permit <br />Pump Inspection By:2;�7 <br />� Date 0 WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS `s � i 7, i t J <br />Fi <br />PE SC Received Check#/ <br />Codes Info BY Cash <br />Amount Date Permit! Invoice # I Well ID# <br />Remitted Service Re uest # <br />L 38J OS -0 <br />77 22 <br />I i i <br />I I <br />I I i <br />t <br />EM04346 IOP-Sr-021_%Pane 1 oft (1 IV61 l Pump Nm,t <br />t 14 7610 Z 7V1 <br />