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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKrON CA 95205-6232 (209)468420 <br /> NON-REFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOBADDRESS 432 W Sneed Rdrn <br /> cm21PFrench Camp 95231 <br /> CROSS STREET I!fiL APN 7�OZ�60 PARCEL SIZE LAND USE APPLICATION# V <br /> Ina <br /> OWNERNAME FrPr1 Rnr-P1 i PHONE 209-6,49-4559 m <br /> OWNERAODREss 5616 Havencrest Circle CrrY/STATE/ZIPStockton,Ca 95219 <br /> oc, n —M Purvianc,Q Drillers, INC PHONE209-887-3554 <br /> CONTRACTOR ADDRESS P-0- BOX 64 CITY/STATE:/ZIP-Linden CA 95236 <br /> SUBCONTRACTORICONSULTANT PHONE <br /> SUBCONTRACTORICONSULTANT ADDRESS CRY/STATEIZIP <br /> LICENSE k C-57 _C-61 D-09 ❑Other NUMBER 377923 EXPIRATION DATE 7/31/21 <br /> BILLING PARTY: --OWNER CONTRACTOR G SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)rl Dibromochloropropane(4392)G Arsenic(4393) <br /> INTENDED USE Domestic/Private ❑Imgation/Ag6cuitura4 L Industrial ::Water Quality Monitoring '_Soil Sampling/Characterization <br /> Public Water System <br /> If difrerent from Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK =New Well C Replacement Well L Well Alteration/Modification ;;Other <br /> : <br /> #efbo �^ <br /> WENT Well(s) 4o wells C:Soil BOrin s Xofborin s Geotechnical <br /> Out-Of-Service Well _Out-OfService Well Renewal �Cross-Connection Repair <br /> New Pum Pum Replacement Pum Repair =Raise Well CasingVED <br /> WELL CONSTRUCTION AUG <br /> Drilling Method Mud Rotary -Air Rotary Auger Cable Tool Push Point _. Other 2020 <br /> Proposed Well Depth ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size <br /> =Conductor Casing in diameter / Conductor Casing Depth ft NI COUNTY <br /> Well Casing Diameter_in Thickness/Gauge/ASTMSchad Steel C Plastic 7 Stainless Steel 'OtheHEA ENTAL <br /> Grout Seal Depth ft Neat Cement(941b bag6-10 gal water) Sand Cement sack ix17 gal water R rMENT <br /> 7.Bentonite(20%solids) :1 Other <br /> Grout Placement Method Pumped a Free Fall L Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By =Driller =Pump Contractor C Other <br /> Concrete Pedestal"Dimensions:Width It Length ft Thick in ❑Christy Box ^Stove Pipe <br /> PUMP SubmersibleC Turbine 7.Other HP L Pump Set It 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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> SIGNED\ i G7.-� �-LY�C TITLE l .�<� DATE 4L b'.IjJ <br /> v <br /> ------------ <br /> I 3p- 11 <br /> I� <br /> C <br /> U <br /> ( 11 Tt 11 Z <br /> / DEPARTMENT USE ONLY <br /> Application Accepted By Date OiAJ area ) �l 0, Employee ID# r' <br /> Grout Inspection By Date ❑ SPECIALWell Permit <br /> Pump Inspection By �t a.L•5 ` ��I- Date Q\,\\l14L 0 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Cheek#/ Amount pe�td <br /> Codes Info Cash Remitted Date Service Re oast# Invoice# Well IO# <br /> END 43-as amirLe19 —F06 2—;2) / <br /> ( WELL/PUMP PERMIT <br />