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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1568 EAST HAZELTON AVENUE-STOCKTON CA 95205-5232(208)468-3420 <br /> NON-REFUNDABLE PERMIT WWW.S]Clov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> S.Escalon , m <br /> JOB ADDRESS 1575 CITy21P Farmington,CA =+ <br /> In <br /> CROSS STREET Copperopolis Rd APN 1871 5001 PARCEL SIZE LAND USE APPLICATION# D <br /> v <br /> OWNER NAME FJS Ranches PHONe209-463-1456 �+ <br /> OWNERADDRESS _ 2928 Dwight Wy CITY/STATE21P Stockton,CA <br /> CONTRACTOR Purviance Drillers, INC PHQNE209-887-3554 <br /> CONTRACTOR ADDRESS P-0- BOX 64 CITY/STATEIZIPLinden CA 95236 <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/7JP <br /> LICENSE X C-57 C-61 -:D-09 Other NUMBER 377923 EXPIRATION DATE 7/31/21 <br /> BILLING PARTY: -.OWNER CONTRACTOR l; SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING.C General Mineral/Coliform Bacteria(4391)'-]Dibromochloropropane(4392)r;Arsenic(4393) <br /> INTENDED USE E Domestic/Private Irrigation/Agricultural Industrial C Water Quality Monitoring a Soil Sampling/Characterization <br /> Public Water System �A <br /> \�� <br /> If different from Owner Water System Name contact Name or Phone Number <br /> ( 'tr/v <br /> TYPE OF WORK XNew Well i s Replacement Well C Well Alteration/Modification ❑Other <br /> Monitoring Well(s) #of wells 7 Soil Borin s #of borings #of borings <br /> D <br /> 9O ❑Geotechnicalg <br /> C Out-Of-Service Well Li Out-Of-Service Well Renewal :]Cross-Connection Repair / 2 <br /> New Pum .1 Pum Re lacement r i Pum Repair r.;Raise Well Casing < Q �O�O <br /> WELL CONSTRUCTION J <br /> Drilling Method (Mud Rotary .:Air Rotary i Auger ::Cable Tool Push Point L' Other EA/JOA <br /> U/N C <br /> Proposed Well Depth4?-ft Excavation�_in diameter Open Bottom .1 Gravel Pack/Gravel Size n r MFI�/O�N <br /> Conductor Casing in diameter / Conductor Casing Depth ft pq R <br /> Well Casing Diameter&in Thickness/Gauge/ASTM Sched ..20 )(Steel 11 Plastic ❑Stainless Steel .1 Other ENT <br /> Grout Seal Dep 'r`�ft ;Neat Cement(94 lb ba9/5-10 gal water) Sand Cement 10,5 sack mix/7 gal Water <br /> Bentonite(20%solids) D Other <br /> Grout Placement Method Pumped G Free Fall C Other -i Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller G Pump Contractor L Other <br /> C Concrete Pedestal I;Dimensions:Width ft Length It Thick in G Christy Box Stove Pipe <br /> PUMP Submersible:"1 Turbine -1 Other HP 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 /> JANCE NOTICE REGI P IZ "ASE F.,4 [ F .. }_pl.r'. aS.i..C•�,T..1 1..'tn1 <br /> SIGNE L/� TITLE ... <br /> DATE <br /> i <br /> -TFI <br /> ------------- <br /> 11 <br /> I � <br /> / ll DEPARTMENT USE ONLY <br /> Application Accepted By ��Lv Date_ Area Employee ID# <br /> Grout Inspection B / <br /> P Y � Date �S` /�� 7r,2.Ci 1 SPECIAL Well Permit <br /> Pump Inspection By Date_ ❑ WAIVER Received <br /> Soil Boring Inspection By Date_ Constructed Well Depth ft <br /> COMMENTS <br /> PE I SC Received Check#/ Amount Permit/Codes Indo Cash Remitted Date Service nest# Invoice# Well ID# <br /> `ISE;s l ,U �. J' '' <br /> EH043-06 6/11/2019 ! _f `� WELL/PUMP PERMIT <br />