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WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1668 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468-3420 <br /> NON-REFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES'I YEAR FROM DATE ISSUED <br /> JOB ADDRESS 10903 E Ada Ave cm,2lP Stockton CA 95215 Sn <br /> nn zz I _ m <br /> CROSS STREET. �r'C4n , APN �QJ1�lo Us SV o <br /> _ PARCEL SIZE d� LAND USE APPLICATION# v <br /> a <br /> OWNER NAME Laverne Gardner PHONE5 10-2 0 5-7 5 0 4 N <br /> OWNERADDRESS 10903 E Ada Ave CITYISTATE/ZIPtockton CA 95215 <br /> CONTRACTOR Purviance Drillers, INC PHONE209-887-3554 <br /> CONTRACTOR ADDRESS P.O. Box 64 CITYISTATE/ZIPLinden CA 95236 <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTORICONSULTANT ADDRESS CITY/STATE/ZIP <br /> LICENSE / C-57 _C-61 _D-09 Other NUMBER 77 7 EXPIRATIONDATE T �� <br /> BILLING PARTY: `.OWNER _.CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:[7 General Mineral/Coliform Bacteria(4391)LI Dibromochloropropane(4392)11 Arsenic(4393) <br /> INTENDED USE Q Domestic/Private D Irrigation/Agricultural [1 Industrial I1 Water Quality Monitoring D Soil Sampling/Characterization <br /> Public Water System <br /> H different from Omer Water System Name Contact Name or Phone Number <br /> TYPE OF WORK D New Well 1 1 Replacement Well 2 Well Alteradon/Modification D Other <br /> Monitoring Well(s) #of wells D Soil Borings) #of borings D Geotechnical #of borings <br /> Out-Of-Service Well a Out-Of-Service Well Renewal C!Cross-Connection Repair <br /> El New Pump Pump Replacement Pump Repair C Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method _Mud Rotary Air Rotary Auger -'Cable Tool D Push Point _ Other <br /> ,Proposed Well Depth ft Excavation in diameter _3 Open Bottom D Gravel Pack/Gravel Size n dieml�r <br /> Conductor Casing in dlameter / Conductor Casing Depth R ft ��FA <br /> Well Casing Diameter_in ThicknesslGaugelASTM Schad Sieel Plastic tl Stainless Steel D Other e\ V,w <br /> Grout Seal Depth ft Neat Cement(94 lb bag/5-10 gal water) �j Sand Cement sack mix17 gal water D <br /> J Bentonite(20%solids) D Other JUVI <br /> A <br /> Grout Placement Method Pumped Free Fall L Other Retardant I Accelerator(name) 252020 <br /> PEDESTAL Installed By C Driller L`Pump Contractor L Other <br /> ! <br /> D Concrete Pedestal Dimensions:Width ft Length ft Thick in C Christy Box C- /IV <br /> MEN�ONTy <br /> PUMP Submersible:!Turbine C Other HP / Pump Set _ft Standing Water Level <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN 7' <br /> CURRENT <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 /> WORKER PENSATION LAWS. <br /> SIGNED / ,E NOTICEREQLIIRFi�FOR iNSPEC ON:, "_FASE CAL.!(20995/,7697 <br /> / Coo <br /> TITLE DATE <br /> Htill, I- <br /> _7 <br /> 1 _ <br /> J \ I <br /> TT <br /> Ir <br /> i I <br /> I <br /> I <br /> DEPARTMENT USE ONLY <br /> i <br /> Application Accepted By L Date Area 7 4fle Employee ID# <br /> Grout Inspection By Date :7 SPECIAL Wel{Permit <br /> Pump Inspection By (�,v t.5< ( L.%.i — Date L rI WAIVER Received <br /> Sol Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Check#) Amount Date Permit! Invoice# Well ID# <br /> Codes Info Cash Remitted Se ry Re uest# <br /> i:x J O ' ,5a- .I �.. <br /> EHD 4306 6It 1!2019 WELL/PUMP PERMIT <br />