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i WELL/PUMP PERMIT 1�/!�� <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468. b. <br /> r NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> French campRdLnJOB ADDRESS CITY/ZJP Ripon 95366 <br /> m <br /> CROSS STREET �,� APN 203-080-23 PARCEL SIZE ' LAND USE APPLICATION# <br /> OWNER NAME Wen Chang Su PHONE 209-402-8656 y <br /> OWNER ADDRESS 4204 Paquerette Cir CITY/STATEIZIPModesto, CA 95356 <br /> CONTRACTOR Purviance Drillers , Inc PHONE 209-887-3554 <br /> CONTRACTOR ADDRESS P O R o X 64 CITYISTATEIZJP Linden , C a 95236 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATEIZJP <br /> LICENSE IXC-57 D C$1 D D-09 D Other NUMBER 377923 EXPIRATION DATE 7/3 1/1 9 <br /> DOMESTIC WELL SAMPLING:C General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domeslic/Private Irrigation/Agricultural n Industrial C Water Quality Monitoring D Soil Sampling/Charactenzation <br /> U Public Water System pa <br /> If r ifferent from Owner Water System Name Contact Name or Phone Number PAY'�„, <br /> TYPE OF WORK D New Well Replacement Well C Well AlterationlModification C Other °��IV <br /> ❑Monitoring Weli(s) #of wells C Soil Boring(s) #of boongs I Geotechnical #of borings C <br /> �/ <br /> e/ p <br /> U Out-Of-Service Well L-Out-Of-Service Well Renewal U Cross-Connection Repair 0 <br /> D New Pump n Pump Replacement F Pump Repair )Raise Well Casing <br /> WELL CONSTRUCTION )p/��AN' "° 8 ®p^ <br /> Drilling Method)(Mud Rotary D Air Rotary ")Auger 7 Cable Tool -1 Push Point ❑ Other qQ rJtd <br /> Proposed Well Depth v�b 0 ft Excavation 1111liy in diameter Open Bottom Gravel Pack/Gravel Size in dMIrQ /�pN/N CO(J <br /> ❑Conductor Casing-Y/A—in diameter / Conductor Casing Depth ft W pip ENTq� <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ,/Yf, X Steel U Plastic L Stainless Steel i_I Other �RT/(}�N1 <br /> Grout Seal Depth /00 ft L Neat Cement(94 Ib bag/5-10 gal wated )(Sand Cement 10.3 sack mix/7 gal water <br /> U Bentonite(20%solids) �]Other <br /> Grout Placement Method Ypumped C Free Fall )Other =Retardant/Accelerator(name) <br /> PEDESTAL Installed By D Driller 7 Pump Contractor Other <br /> 1 Concrete Pedestal CDimensions:Width ft Length ft Thick in 7 Christy Box -1 Stove Pipe <br /> PUMP U SubmersibleE)Turbine �]Other HP Pump Set it Standing Water Level ft <br /> 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 /> MM 24 D NCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGN TITLECo�rpor Sectary DATE 2/8/19 <br /> / V` <br /> 1 <br /> I <br /> • L" l <br /> 4 e-da LZ <br /> YEP! RTMENT USE ONLY t <br /> Application Accepted By ` —1 Date �� Area ( Employee ID# � ✓) <br /> Grout Inspection ByAAA Dale~� 7 SP CIAL W@II Permit <br /> Pump Inspection By Date I WAIVER Received <br /> Soil Boring Inspection By1 Date Constructed Wg11 Depth ft <br /> CgVMENTS �X5LLIV,G )kms Y\�Qs7� f Q Cr t�IC�rnV )I <br /> PE SC Received Chec Amourtr Date Permit/ Invoice# WellID# <br /> Code Info Remitted Service R uest# <br /> C' Zffa 3 /7-5 <br /> � I IE 34-2-21 <br /> � <br /> EHo43-06 =1116 WELL/PUMP PERMIT <br />