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' p✓ <br />(3?31 <br />WELUPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 23459 E Milton Rd CITY/Lipp L i n d e n Z m <br />ROSS STREET N Fine APN a 9 3 �� ,00 7 PARCEL SIZE I If � - LAND USE APPLICATION # O <br />DINNER NAME Solari, Andy & Edith ry� r T !PHONE m209-481-4332 In <br />)wNER ADDRESS PO DU D X /88 8 CITY/STATE/LP Linden, C A 95236 <br />y <br />:ONTRACTOR Purviance Drillers, Inc ?no -887 <br />CONTRACTOR ADDRESS P O B o% 64 <br />ADDRESS <br />LICENSE LXC-57 U C-61 U D-09 LI Other <br />CITYfSTATE/ZIP <br />_— CITY/STATEZP_ <br />NUMBER 377923 <br />PHONE — 3 -)-)4 <br />Linden,Ca 95236 <br />PHONE <br />EXPIRATION DATE 7/31/19 <br />DOMESTIC WELL SAMPLING: r General Mineral/Coliform Bacteria (4391) C Dibromochloropropane (4392) _i Arsenic (4393) <br />INTENDED USE n Domestic/Private * Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br />U Public Water System <br />If different fmm Owner. Water System Name <br />Contaq Name or Phone Number <br />TYPE OF WORK 0 New Well E Replacement Well C Well AlteratiorUModification U Other <br />11 Monitoring Well(s) #of wells F. SoilBoting(s) #of borings CIGeotechnical sofborings <br />U Out -Of -Service Well L Out -Of -Service Well Renewal D Cross -Connection Repair <br />11 New Pump C Pump Replacement C Pump Repair -1 Raise Wen Caci— <br />W <br />(� 5' <br />Drilling Method M Mud Rotary r_ Air Rotary ❑ Auger/ ❑Cable Tool Ll Push Point [7 Other <br />Proposed Well Depth -5 it Excavation �Q I� Z in diameter ■ Open Bottom C Gravel Pa */Gravel Size <br />rl Conductor asing in diameter / Conductor Casingin diameter /! <br />Well Casing Diameter <br />n Thickness/Gauge/ASTM Sched O Depth ry I I/ <br />2S II` Steel U Plastic L' Stainless Steel ❑ Other. `/ <br />Grout Seat Depth /01 14 ft u Neat Cement (94 /b bays -10 gal water) t Sand Cement /0.3 sack mix/7 gal water <br />U Bentonite (20% solids) U Other 1r <br />Grout Placement Method i Pumped U Free Fall U Other �n "'r � �yGJ <br />C Retardant / Accelerator (name) pomp <br />PEDESTAL Installed By 6 Driller D Pump Contractor ❑ Other <br />it Concrete Pedestal CDimenstoos: Width ft Length ft Thick Ac y. al <br />in ED] Box U Stove Pipe <br />PUMP U SubmersibleU Turbine 7 Other `� <br />HP Pump Set ft Standing Water Level ft <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN CL 1' <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 J <br />WORKERS COMPENSATION LAWS. �y I� <br />MINI 24,HQM AMANCE NOTICE REQUIRED FOR INSPE l l <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />EHD 43-M 6,01/16 <br />CTIONS - PLEASE CALL ((209) � /17 <br />346f <br />Pec TIS Corpor Sectary DATE 1 / <br />Area �i ` G Employee ID# <br />❑ ISPECIAL Well Permit / <br />1 'WAIVER Received <br />WELL /PUMP PERMIT <br />