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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.,5gov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESSv <br /> _SdQQ E Harna4z Tana CrTY21P 7.nAi Q-S-Jd(1 m <br /> CROSSSTREET wells Lane APN Dl,- Od <br /> PARCEL SIZE LAND USE APPLICATION# G <br /> OWNER NAME Deana Kirby PHONE 209-986-5885 v <br /> OWNER ADDRESS P.O. BOX 100 CrrY1STATE21P Acampo,CA 95220 <br /> CONTRACTOR Purviance Drillers, INC PHONE209-887-3554 <br /> CONTRACTOR ADDRESS P-0- BOX 64 CITYISTATErMpLinden CA 95236 <br /> SUBCONTRACTORICONSULTANT PHONE <br /> SUBCONTRACTORICONSULTANT ADDRESS Cny/STATEMP <br /> LICENSE %C-57 _C-61 D-09 C Other NUMBER 377923 EXPIRATION DATE 7/3 1/2 1 <br /> BILLING PARTY: -OWNER E CONTRACTOR a SUBCONTRACTOR/CONSULTANT <br /> DomFsnc WELL SAMPLING:G General Mineral/Coliform Bacteria(4391)E,Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE A"Domestic/Private -- Irrigation/Agricultural ❑Industrial C Water Quality Monitoring -Soil Sampling/Characterization <br /> Public Water System <br /> IfaiHemntfrom Owner Water System Name Contact Name or Phone Number <br /> TYPE OF WORK _:New Well 7 Replacement Well G Well AlteratiDn/Modification Other <br /> Monitoring Well(s) #of wells SOiI BOring(5) #or borings C Geotechnical s or borings <br /> Out-0f-Service Well 5-Out-Of-Service Well Renewal Cross-Connection Repair <br /> =New Pump 4urnp Replacement -_Pump Repair =Raise Well Casin <br /> I WELL CONSTRUCTION �� <br /> Drilling Method Mud Rotary C Air Rotary Auger Cable Tool it Push Point C Other ' <br /> Proposed Well Depth ft Excavation in diameter -1 Open Bottom ❑Gravel Pack/Gravel Size in diameter VFX <br /> Conductor Casing in diameter / Conductor casing Depth tt �� <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched C Steel =Plastic D Stainless Steel Other <br /> Grout Seal Depth ft ❑Neat Cement(94 Ib bag15-10 gal water) Sand Cementixx((jj�����l water 20 0 <br /> Bentonite(20%solids) C Other �Cr Q <br /> Grout Placement Method Pumped Free Fall ❑Other Retardant/Accelerator(name) i /�/ cooly . <br /> PEDESTAL Installed By �i Driller =Pump Contractor G Other TMC <br /> Concrete Pedestal';Dimensions:Width It Length it Thick In D to <br /> Christy Box ❑Sve Pipe ENT <br /> PUMP Submersible;Turbine ;Other HP Pump Set yu ft Standin0 Water Level /Pd 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. 1 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 L VV-S. <br /> TIRE 6 fV C. - %1 DATE <br /> I I <br /> I II I <br /> I I <br /> I of <br /> I I <br /> 1 <br /> I I II I <br /> IT <br /> i I <br /> I I <br /> I II <br /> I <br /> DEPARTMENT USE NLY �/ f <br /> Application Accepted By '�- e/L� Date 7 ;' �J 7 G�j <br /> Area Employee ID# <br /> Grout Inspection By Date ] SPECIAL Well Permit <br /> Pump Inspection ByDate 1f:is ] WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Permit/ <br /> Codes Info Cash Remitted Date Service Re uest# Invoice C Well Ip# <br /> 1 J 1.21 <br /> I P <br /> EH043-06 6/112079 <br /> WELL/PUMP PERMIT <br />