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WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468-3420 <br /> NON-REFUNDABLE PERMIT www.sigov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 13777 E Comstock Rd CrrYID Linden CA 95236 <br /> CROSS STREET N JackTone Rd APN M11920—:?o PARCEL SIZE � <br /> L_LAND USE APPLICATION# p <br /> OWNERNAME Nikki BArr PHONE209-470-1445 y <br /> OWNERADDRESS 13777 E Comstock Rd CITY/STATEMpLinden Ca 95236 <br /> CONTRACTOR Purviance Drillers, INC PHOME209-887-3554 <br /> CONTRACTOR ADDRESS P.O. BOX 64 Cm/STATEIZIPLinden CA 95236 <br /> SUBCONTRACTORICONSULTANT PHONE <br /> SUBCONTRACTORICONSULTANT ADDRESS CITY/STATE/Z1P <br /> LICENSE J(;C-57 C-61 D-09 7iOther NUMBER 3�7ef�J 7EXPIRATION DATE <br /> BILLING PARTY: OWNER [;CONTRACTOR G SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:L General Mineral/Coliform Bacteria(4391)C Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE F DomesticfPrivate '_'Irrigation/Agricultural C Industrial -Water Quality Monitoring L'Soil Sampling/Characterization <br /> —1 Public Water System <br /> 7 <br /> If different from Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK : New Well C Replacement Well Well Alteration/Modification Other <br /> _ Monitoring Well(s) #ofwells ❑SailBoring(s) sorborings Geotechnical ucfborings <br /> Out-Of-Service Well Ll Out-Of-Service Well Renewal Cross-Connection Repair <br /> L New Pum Y—Pump Replacement L Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method G Mud Rotary L31 Air Rotary ❑Auger 7 Cable Tool Push Point 11 Other <br /> Proposed Well Depth ft Excavation in diameter 1]Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad Steel U Plastic ❑Stainless Steel 11 Other <br /> Grout Seal Depth ft Neat Cement(94 lb bag/5 10 gal water) U Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) C Other <br /> Grout Placement Method -Pumped d Free Fall C Other ' Retardant/Accelerator(name) <br /> PEDESTAL Installed By -- Driller C Pump Contractor L Other <br /> Concrete Pedestal 1:Dimenslons:Width It Length It Thick in Christy Box C Stove Pipe <br /> PUMP . Submersible Turbine �OtherHP Pump Set ft 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 /> NOTICE -. <br /> SIGNEIT` {� / TITLE DATE <br /> vNT <br /> ED <br /> ! ----J4447-F <br /> p N IC ' Y <br /> TMEMT <br /> I <br /> DEPARTMENT USE ONLY <br /> Application Accepted By `�' 'C-���- Date L� Area �+r Vii ' Employee ID# <br /> Grout Inspection By Date -I SPECIAL Well Permit <br /> Pump Inspection By c��� S�u L V Date Ir (f 11? ")v F1 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#! Amount PenniU <br /> Codes Info B Cash Remitted Date ervice Re uest# Invoice# Well ID# <br /> 12 - <br /> I <br /> ENn a3-e6 5/111201e 6x ' A)�'2a3 733 <br /> WELL!PUMP PERMIT <br />