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WELL/PUMP 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 ADDREss1 1 339 N/ Wimer Rd CITY/ZIP Linden 95236 m <br /> CROSS STREET ;u APN O 6 7 2 8 O 1 5 PARCEL SIZE '�_,LAND USE APPLICATION# S <br /> OWNER NAME Michael & Staige DeBenedetti PHONE 209-366-7425 y <br /> ox Lodi, 5 <br /> OWNER ADDRESS CITY/STATFlZIP CA <br /> CONTRACTOR Purviance Drillers , Inc PHONE 209-887-3554 <br /> CONTRACTOR ADDRESS P 0 B o X 64 CITylSTATEIZIP Linden , C a 95236 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE LXC-57 D C-61 I D-09 IJ Other NUMBER 377923 EXPIRATION DATE <br /> DoMEsnc WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392)_.Arsenic(4393) <br /> INTENDED USE -Domestic/Private Irrigation/Agricultural Industrial F Water Quality Monitoring I 1 Soil Sampling/Characterization <br /> L Public Water System <br /> If different from Owner- Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well E Replacement Well E Well AlleratiordModification D Other <br /> :'. Monitoring Well(s) #of wells E Soil Boring(s) n of boongs I Geotechnical #of borings <br /> J Out-Of-Service Well L Out-Of-Service Well Renewal _!Cross-Connection RepairJO/� <br /> -I New Pump I-- Pump Replacement I Pump Repair -I Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method R Mud Rotary C Air Rotary 7 Auger -1 Cable Tool -I Push Point n Other r <br /> Proposed Well Depth4-10 ft Excavation E� -7.xcavation /4V 31Y in diameter Open Bottom F Gravel Pack/Gravel Size in deteriam08 (y <br /> 7 Conductor Casing�in diameter / Conductor Casing Depth ft SAA/J <br /> Well Casing Diameter S� in Thickness/Gauge/ASTM Sched •/F9 '(Steel J Plastic L Stainless Steel _Other_ FA/p/ OU//v L.OUN <br /> Grout Seal Depth 00 f ft J Neat Cement(94 Ib bag/5-10 gal water (Sand Cement (0. 5 sack mix/'{ �p INT <br /> r1` <br /> AL <br /> Bentonite(20%solids) J Other A <br /> Grout Placement Method Pumped :7 Free Fall J Other = Retardant/Accelerator(name) SENT <br /> PEDESTAL Installed By Driller 7 Pump Contractor Other <br /> Concrete P destal-Dimensions:Width ft Length ft Thick in -1 Christy Box J Stove Pipe <br /> PUMP :J SubmersibleD Turbine -3 Other HP Pump Set fl 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 LAWS. <br /> M UM 24 H A ANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7 97 <br /> TITLE Corpor Sectary DATE 2/8/ 19 <br /> t <br /> r <br /> D PARTMENT USE ONLY <br /> Application Accepted By Date ! '20 1 Area Employee ID# <br /> Grout Inspection By I Date ` 1 S CIAL ell Permit <br /> Pump Inspection By Date \ I WAIVER Received ,—/7 JIB <br /> Soil Boring Inspection By Date Constructed Well Depth v V R <br /> COMMENTS A I D <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# WellID# <br /> Codes Info Cash Remitted Service R uest# <br /> r_ 2WHOM�Lcl <br /> EHD43-06 8101/16 WELL/PUMP PERMIT <br />