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WELL/PUMP PERMIT C ✓'* <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 /> 1696 N . Fscalon Bellota Linden , CA 952.36 <br /> JOB ADDRESS CIN/LP D <br /> Milton <br /> CROSS STREET APN 09325001 PARCEL SIZE3 01�LAND USE APPLICATION# m <br /> OWNER�iayl7e (Watkins/K&A Watkins Farm parteners}AMw <br /> OWNER ADDRESS` • " • B O X 4 7 2 a►b 1 IM/tTM/ C j CITY/STATFJZI L i n d e n , CA 95236 <br /> CONTRACTOR <br /> Purviance Drilles , Inc . PHONE 209-887-3554 <br /> (� <br /> CONTRACTOR ADDRESS rT�"B o X 64 CITY/STATE/LP Linden , `n l A 9`C <br /> 1 2 3 6 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS 1CI'T7Y/SST.A/�TE/ZIIPPj 1 <br /> LICENSE C-57 C-61 D-09 Other NUMBER 3 / / j j— ExPIRATION DATE ,/ 31 r `' <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section <br /> INTENDED USE Domestic/Pdvate Irrigation/Agricultural Industrial i- Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner Water System Name contact Nam or Hnone NumDer <br /> TYPE OF WORK XNew Well Replacement Well U Well Alteration/Modification u Other <br /> #of bodrKis #or borings <br /> Monitoring Wells) #of wells F1Soil Boring(s) Geotechnical <br /> Out-Of-Service Well Ff Out-Of-Service Well Renewal n Cross-Connection Repair <br /> New Pump I Pump Replacement ❑Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method KMud Rotary Air Rotary I Auger I_I Cable Tool Push Point Other <br /> Proposed Well Depth / y ft Excavation ZZ- in diameter X Open Bottom I Gravel Pack/Gravel Size in diameter <br /> Conductor Casing � �' in diameter / Conductor Casing Depth ft <br /> //_ <br /> Well Casing Diameter/0 in Thickness/Gauge/ASTM Sched -2Z1 Z1 YSteel I i Plastic Stainless Steel I Other <br /> Grout Seal Depth ICO—t ft I Neat Cement(94 lb bagV5-10 gal water) <Sand Cement /0, 3 Sack mix17 gal water <br /> I I Bentonite(20%solids) I Other <br /> Grout Placement Method Pumped I Free Fall I Other _I Retardant/Accelerator(name) <br /> PEDESTAL Installed By i'Driller Pump Contractor I Other <br /> Concrete Pedestal Dimensions:Width ft Length ft Thick in I I Christy Box 1 I Stove Pipe <br /> PUMP Submersible Turbine Other HP Pump Set It 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 <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I 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 LA <br /> MINI71'��/f,J�M 24 A /A�NCE NOTICE REQUIRED FQR INSPECTIONS-PLEASE CALL(209)913 7f <br /> SIGNED <br /> NT <br /> �'� - TITLE Corporate e c r e t a bj % /18 <br /> 2 <br /> PA YM, <br /> r <br /> U1y 2018 <br /> N OAQUIN <br /> V/RDNM COUNTY <br /> L H DEPAR MENTI <br /> PAMA 4; A TME NT USE NLY <br /> Application Accepted By Date Area �y/ N "/ Employee ID#v V Q <br /> Grout Inspection By L4jAate 4 oi� oil Permit <br /> Pump Inspection By Date -1 WAIVER Received <br /> Soil Boring In ection By Date Constructed Well Death ft <br /> COMMENTS � -1 14 0 /f A r 1 6 �Wtj' r , , <br /> 7Y'v _ u <br /> PE SC Received Amount Permit/ <br /> Codes Info B Cash Remitted Date Service Re uest# Invoice# Well ID# <br /> 76 <br /> EHD 43-06 WELL/PUMP PERMI- <br /> 4/30/12 <br />