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WELL/PUMP 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 16860 E Eight Mile Rd crrY21P Linden, CA 95236 ti <br /> D <br /> CROSS STREET N Tully Rd APN 09116001 PARCELSIZE 'ic.--t LAND USEAPPL1cATION# p <br /> OWNERNAME V&A Lagorio PHONE 209-482-6324 <br /> OWNER ADDRESS 14625 E Costock Rd CnY/STATE/LP Linden, CA 95236 <br /> CONTRACTOR Purviance Drillers, Inc PHONE 209-887-3554 <br /> CONTRACTOR AD DRESS PO Box 64 CrrvISTATEZIr Linden, CA 95236 <br /> SUBCONTRACTOR/CONSULTANT n/a PHONE <br /> SUBCONTRACTORICONSULTANT ADDRESS CITY/STATE21P <br /> LICENSE R C-57 C C-61 C D-09 i!Other NUMBER 377923 EXPIRATION DATE 7/31 /21 <br /> BILLING PARTY: E OWNER 'XCONTRACTOR C SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING:U General MineraVColiform Bacteria(4391)�i Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE 1 Domesfic/Private IKIrrigafion/Agricultural E Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK C New Well L Replacement Well D Well Alteration/Modification D Other <br /> 0 Monitoring Well(s) #of wells D Soil Bodng(s) a of borings D Geotechnical n of bodngs Y <br /> D Out-Of-Service Well !i Out-Of-Service Well Renewal G Cross-Connection Repair R �/M/.�� <br /> V <br /> 0 New Pum -Pum Re lacement Pum :1Re air Raise Well Casing /c\ ^^ <br /> WELL CONSTRUCTION `O <br /> Drilling Method D Mud Rotary [i Air Rotary C Auger ❑Cable Tool D Push Point D Other Op <br /> n <br /> Proposed Well Depth ft Excavation in diameter :I Open Bottom D Gravel Pack/Gravel Size ameter J <br /> Conductor Casing in diameter I Conductor Casing Depth ft JO �O 0 <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched r:Steel 0 Plastic ❑Stainless Steel i i Other FNS/ /IV <br /> Grout Seal Depth ft C Neat Cement(94 Ib bagl&10 gal water) 0 Sand Cement _sack miXA g NMFN0VNT <br /> E <br /> Bentonite(20%solids) 0 Other PgRTF Y <br /> Grout Placement Method ❑ Pumped n Free Fall D Other L'Retardant!Accelerator(name) Nr <br /> PEDESTAL Installed By 0 Driller L:Pump Contractor E Other r <br /> Concrete Pedestal DDimensions:Width ft Length ft Thick in D Christy Box I1 Stove Pipe <br /> PUMP :!Submersibl!:X Turbine D Other HP Pump Set 2000 ft Standing Water Level fS/ 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 /> ?dli 9U%I- JANCE NOTICE REQUIRED FOP,NSPECTIONS-PLEASE CALL(2t 9)283-7660,=. <br /> SIGNED TrTLECorporate Secretary DATE 4/21/20 <br /> I � <br /> �y a� <br /> T l DEPARTMENT 11EI0 <br /> t v <br /> Application Accepted By_! L' L- Date cy LU 7 O Area �f Employee ID# i l <br /> Grout Inspection By { Date _J SPECIAL Well Permit <br /> Pump Inspection By �V..Ni�r�„ �Y Date_�-41j') [7 WAIVER Received <br /> Soil Boring Inspection By Date `�`— Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Check#/ Amount Permit/ <br /> Codes Info B Cash Remitted Date ervice Request# Invoice# Well ID# <br /> EHD 43-08 8/112019 <br /> WELL!PUMP PERMIT <br />