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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 /> Joe ADDRESS 23502 N McIntire Rd C.Y/ZIP Clements m <br /> CROSS STREET Hwy 12 APN 0 2 314 019 PARCEL st.Eino D USE APPLICATION# 9 <br /> A <br /> OWNER NAME Mike �1'q}enente PHONE 209-605-3898 <br /> OWNER ADDRESS 10051 Escalon Bell6ta Rd CITY/STATE/ZJP Escalon, CA 9532.0 <br /> CONTRACTOR Purviance Drillers , Inc p,,N, 209-887-3554 <br /> CONTRACTOR ADDRESS PO Box 64 CRY/STATEIZIPL 1 n d e n , C A 95236 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATFJZIP <br /> LICENSE X C-57 U C-61 D D-09 D Other NUMBER 377923 EXPIRATION DATE 7/31/19 <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392)-Arsenic(4393) <br /> INTENDED USE 0 Domestic/Private Irigation/Agricukural G Industrial C Water Quality Monitoring 0 Soil Sampling/Characterization <br /> 0 Public Water System <br /> If different from Owner Water system Name Contact Name or Phone Number <br /> TYPE OF WORK )(New Well C Replacement Well D Well Alteration/Modification 7 Other <br /> 0 Monitoring Wells) #of wells c Soil Boring(s) a 0f borings C Geotechnical tT of borinp <br /> D Out-Of-Service Well C Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> C New Pump C Pump Replacement C Pump Repair D Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method P Mud Rotary C Air Rotary D Auger 0 Cable Tool -1 Push Point 0 Other <br /> Proposed Well Depth It Excavation / 'N in diameter )(Open Bottom E Gravel PacklGravel Size In diameter <br /> ❑Conductor sing�in diameter 1 Conductor Casing Depth ft <br /> Well Casing Diameter Zpn Thidmess/GaugeIASTM Schad ,/Y p XSteel D Plastic C Stainless Steel D Other <br /> Grout Seal Dept +— OG' ft D Neat Cement(94/b bag/5-10 gal water) p.Sand Cement 10.3 sack mbr/7 gal water <br /> C Bentonite(20%sofids) 7 Other <br /> Grout Placement Method 1K Pumped D Free Fall D Other D Retardant/Accelerator(name) <br /> PEDESTAL Installed By XDriller ❑Pump Contractor D Other <br /> 0 Concrete Pedestal CDimensions:Width it Length It Thick in -I Christy Box ❑Stove Pipe <br /> IRPILP 0 SubmersibleO Turbine D Other HP Pump Set it Standing Water Level ft <br /> 1 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 LAWS. <br /> MINI �211ANCE NOTICE REQUIRED(F'OR INSPECTIONS-PLEASE CALLy(209)953-76697 <br /> SIGNED TITLE o r p o r a t e S e c r e t a r PATE o-O <br /> 1 <br /> MENT <br /> EIVED <br /> 0 9 2098 <br /> UIN COUNTY <br /> IINYIHONMENTAL <br /> DEPARTMENT <br /> E A M E N T U E O (eY <br /> Application Accepted By�,,,Attt��'' ' Date AreaEmployee IDk(� <br /> Grout Inspection ByDate &PECIALell Permit <br /> Pump Inspection By Date ;I WAIVER Received <br /> Soil Boring inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received heck#/ Amount Date Permit/ Invoice# WellID# <br /> Codes- info itted S ce Re u t# <br /> EH043-06 a101/16 WELL/PUMP PERMIT <br />