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WELUPUMP PERMIT <br /> SAN JOAGUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232 (209)468-3420 <br /> NON-REFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 2851 N Bozz0.ir�n Rd ry yn crryZF5tockton CA 95215 m <br /> CROSS STREET Ara t a Rd APN_-I 0I p 6 t/ PARCEL SIZE q,7 3 LAND USE APPLICATION# o <br /> OWNER NAME California Fruit Processors,LLC PHONE 209-931-1917 N <br /> OWNERADDRESS 2852 N Bozzano Rd CITY/STATE/ZIP Stockton CA 95215 <br /> CONTRACTOR Purviance Drillers, INC PHONE209-887-3554 <br /> CONTRACTOR ADDRESS P-0- BOX 64 C"ISTATE21PL1nderl CA 95236 <br /> SUBCONTRACTORICONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITYISTATE/ZIP <br /> LICENSE 15 C-57 C-61 _D-09 Other NUMBER 31 74jd-? EXPIRATION DATE <br /> BILLING PARTY: OWNER fi CONTRACTOR 7 SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING:G General Mineral/Coliform Bacteria(4391)is Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE r Domestic/Private )(Irrigation/Agricultural L Industrial Water Quality Monitoring �]Soil Sampling/Characterization <br /> C Public Water System <br /> 1161!m t from Owner Water System Neme Contact Name or Phone Number <br /> TYPE OF WORK '.: New Well ❑Replacement Well 7-Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells Soil Boring(S) #of boangs ❑Geotechnical #of borings <br /> Out-Of-Service Well ::Out-Of-Service Well Renewal U Cross-Connection Repair <br /> New Pump Pump Replacement -- Pump Repair (I Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method _Mud Rotary Air Rotary :)Auger .;Cable Tool 7 Push Point I; Other <br /> Proposed Well Depth It Excavation in diameter .7 Open Bottom f IGavel Pack/Gravel S ze in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched Steel C Plastic L Stainless Steel ❑Other <br /> Grout Seal Depth ft _Neat Cement(94/b bag/5-10 gal water) 1;Sand Cement sack mixR gal water <br /> Bentonite(20%solids) :3 Other <br /> Grout Placement Method Pumped i Free Fall C Other _ Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller =Pump Contractor Other <br /> Concrete Pedestal CDimensions:Width If Length It Thick in S Christy Box ❑Stove Pipe <br /> PUMP Submersible:]Turbine -1 Other HP ) Pump Set ft Standing Water Level ft <br /> I HEREBY CERTI 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. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> L.v W &�CALL 1,2133)'G35,--7697 <br /> SIGNE�'^"�'�ll'ii 'ce. TITLE DATE (o'G <br /> I <br /> PAYME <br /> RECE <br /> JUN 0 2 <br /> SAN 10AOU( C I <br /> HEA'T DEP <br /> i <br /> DEPARTMENT USE ONLY <br /> Application Accepted By `_ — Date cin ' D Area CSC Employee ID# ✓r. <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Lr, =utSG:Ltvt., �y�r� Date ( 'iV ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Permit/ <br /> Codes Info )Cash Remitted Date Service Reguest# Invoice# Well ID# <br /> s P <br /> EHC 43-06 6!1172079 <br /> L 63 2-12- WELL/PUMP PERMIT <br /> l <br />