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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.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> Jos ADDRESS 7338 Orford Rd Cm/ZIP Stockton CA 95215 `ten <br /> m <br /> 101,26P33 m <br /> CROSS STREET N Alpine RD APN PARCEL SIZE a 9-5 o <br /> �I.AND USE APPLICATION# p <br /> A <br /> OWNER NAME Randy Gillies PHONE 209-479-4952 w <br /> w <br /> OWNERADDRESS 7338 Orford Rd CITY/STATE/ZIP Stockton CA 95215 <br /> CONTRACTOR Purviance Drillers, INC PHONE209-887-3554 <br /> CONTRACTOR ADDRESS P-O- BOX 64 CITYISTATE/ZIPLi nden CA 95236 <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP <br /> LICENSE XC-57 C-61 D-09 ❑Other NUMBER 3?192-3 EXPIRATION DATE <br /> BILLING PARTY: ,OWNER L'.CONTRACTOR [: SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:G General Mineral/Coliform Bacteria(4391)'-!Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE omestic[Private f]Irrigaticn/Agricultural � Industrial C Water Quality Monitoring D Soil Sampling/Characterization <br /> Public Water System <br /> If Cifferent from Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK C New Well C Replacement Well G Well Alteration/Modification n Other <br /> Monitoring Well(s) #of wells ❑Soil Soring(s) #of borings D Geotechnical #cf borings <br /> Out-Of-Service Well G Out-Of-Service Well Renewal L Cross-Connection Repair <br /> New Pump 'Pum Replacement D Pump Repair D Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method -Mud Rotary 71 Air Rotary _Auger -Cable Tool ,Push Point I Other <br /> Proposed Well Depth ft Excavation in diameter 7 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 ::Plastic Stainless Steel Other <br /> Grout Seal Depth ft Neat Cement(94/b bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) C Other <br /> Grout Placement Method ' Pumped n Free Fall C Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By G Driller '- Pump Contractor L Other <br /> Concrete Pedestal[:Dimensions:Width ft Length it Thick in C Christy Box D Stove Pipe <br /> PUMP Submersible.,Turbine Other HP Pump Set It Standing Water Level U0 X 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 PLEASE CALL 12" C�.. <br /> SIGNED .TITLE .„ DATE a o� <br /> I <br /> I I <br /> I � I CE ENT <br /> I V FD <br /> I <br /> N 0 5 Z020 <br /> AQUI <br /> N <br /> DEP N COTA LINTY <br /> A R T41ENT <br /> I I <br /> I <br /> �i <br /> DEPARTMENT USE ONLY f� <br /> Application Accepted By �``'— `� DateZ�%L�-' Area Employee ID#, ._ <br /> Grout Inspection By Date -1 SPECIAL Well Permit <br /> Pum Inspection P ection B Y try y� /� (I')ylji�a Date /� ] WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#! Amount Permit/ <br /> Codes Info Date Invoice# Well ID# <br /> ash Remitted Service Request# <br /> OBD 7 <br /> EH0 63-06 6/11/TD79 - l093 733 WELL/PUMP PERMIT <br />