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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1668 EAST HAZELTON AVENUE-STOCKTON CA 95205.6232(209)4683420 <br /> NON-REFUNDABLE PERMIT www.sigov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 1246 Fine Rd CITY/Zip Linden, CA 95236 y <br /> CRosssTRE,�opperopolis 09304076 7 0 <br /> APN PARCEL SIZE f 4�LAND USE APPLICATION# p <br /> OWNER NAME Dwight Michell y <br /> PHONE v <br /> OWNER ADDRESS PO Box 1740 crntSTATF1zIPValleySprings, CA 95236 <br /> CONTRACTOR Purviance Drillers, Inc PHONE 209-887-3554 <br /> CONTRACTOR ADDRESS PO Box 64 CITY/STATE/ZIPLinden, CA 95236 <br /> SUBCONTRACTORICONSULTANT PHONE <br /> SUBCONTRACTORICONSULTANT ADDRESS CITY/STATEMP <br /> LICENSE x C-57 C-61 D D-09 ❑Other NUMBER 377923 EXPIRATION DATE 7 3 1/2 0 <br /> BILLING PARTY: D OWNER $CONTRACTOR D SUBCONTRACTOWCONSULTANT <br /> DOMESTIC WELL SAMPLING:C7 General Mineral/Coliform Bacteria(4391)❑Dibromochloropropane(4392)D Arsenic(4393) <br /> INTENDED USE X Domestic/Private D Irrigation/Agricultural D Industrial D Water Quality Monitoring D Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ❑New Well D Replacement Well D Well Alteration/Modification D Other <br /> D Monitoring Well(s) #ofwelis 2 Soil Borings) #oflwrings D Geotechnical #ofborings <br /> 7 Out-Of-Service Well Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> New Pump u Pump Replacement D Pump Repair D Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method C Mud Rotary i]Air Rotary L'Auger 7 Cable Tool D Push Point D Other <br /> Proposed Well Depth ft Excavation in diameter D Open Bottom L Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched 7 Steel D Plastic n Stainless Steel D Other <br /> Grout Seal Depth ft Cl Neat Cement(94 lb bag/5-10 gal water) D Sand Cement sack m.f7 gal water <br /> Bentonite(20%solids) ❑Other <br /> Grout Placement Method r:Pumped D Free Fall O Other 13 Retardant/Accelerator(name) <br /> PEDESTAL Installed By 'Driller ❑Pump Contractor D Other <br /> D Concrete Pedestal Cl Dimensions:Width ft Length ft Thick in C Christy Box D Stove Pipe <br /> PUMP X Submersible Turbine D Other HPP S t /89 a Standing r <br /> d rt <br /> I HEREBY CERTIFY THAT 1 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 /> n1 <br /> NOTICE REQUIRED FOR IMSPECTIONS-PLEASE CALL(209)953=59-' <br /> SIGNED TITLECorporate Secretary DATE4/21/20 <br /> FF-17 <br /> --------------- <br /> ---------------- <br /> ' c�MFNr <br /> NO <br /> 29 ?020 <br /> 1# <br /> pq �7-4 CNT <br /> FNT <br /> I <br /> DEPARTMENT USE ONLY J f <br /> Application Accepted By e'L Date `>' ��% ��`d area r/ ��(i Employee ID# s Il_ <br /> Grout Inspection By Date 1 1 h IJSPECIAL Well Permit <br /> Pump Inspection By r y-fit+5 �> L-".,o, i 1 'l i Date I51 t; <br /> WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth {t <br /> COMMENTS <br /> PE SC Received Check#! Amount PermiU <br /> Codes Info B Cash Remitted Date Service Request# Invoice# Well ID# <br /> TS 2A' 1,p <br /> EHD 43-06 6/1112019 /J . WELL/PUMP PERMIT <br />