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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 ADDRESS 8916 Shelton Rd /1 cITYIZIP Linden,CA 95236 a <br /> CROSS STREET UT 93Oo m <br /> K/`�f/"��-`-='I /�� APN � PARCEL SIZE I LAND USE APPLICATION# O <br /> OWNGRNAMC Jeremy Coppock PHONE 209-993-9483 m <br /> N <br /> OWNER ADDRESSP-O. BOX 1634 CITYISTATEizIP Linden,CA 95236 <br /> CONTRACT., Purviance Drillers, INC PHONE209-887-3554 <br /> CONTRACTOR ADDRESS P-O. BOX 64 CITYISTATEIZIPLinden CA 95236 <br /> SUSCONTRACTORICONSULTANT PHONE <br /> SUBCONTRACTORICONSULTANT ADDRESS CITYISTATEILIP <br /> LICENSE X C-57 C-61 D-09 Other NUMBER 377923 EXPIRATION DATE 7/3 1/2 1 <br /> BILLING PARTY: OWNER D CONTRACTOR D SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING:0 General MineraUColiform Bacteria(4391)0 Dibromochloropropane(4392)0 Arsenic(4393) <br /> INTENDED USE Domestic/Private E,Irrigation/Agricultural 0 Industrial D Water Quality Monitoring 0 Soil Sampling/Characterization <br /> 0 Public Water System <br /> If different from Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK C New Well a Replacement Well :,Well AlterationlModification C Other <br /> C Monitoring Well(s) #of wells D Soil Boring(s) a of bonngs D Geotechnical #of borings <br /> Out-0f-Service Well G Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pum _'PumpA'Purnp Replacement t-Pump Repair C Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method - Mud Rotary 7 Air Rotary ❑Auger ❑,Cable Tool D Push Point r� Other <br /> Proposed Well Depth ft Excavation in diameter -]Open Bottom n Gravel Pack/Gravel Size in diameter <br /> -Conductor Casing in diameter ! Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched :1 Steel D Plastic D Stainless Steel 0 Other <br /> Grout Seal Depth ft 'Neat Cement(94 Ib bag/5-10 gal water) Sand Cement sack mix,gal water <br /> L Bentonite(20%solids) D Other <br /> Grout Placement Method Pumped Free Fall ❑Other Retardant/Accelerator(name) <br /> PEbESTAL Installed By C Driller C Pump Contractor G Other <br /> Concrete Pedestal Dimensions:Width ft Length ft Thick In ❑Christy Box D Stove Pipe <br /> EU—UP "' ubmersible7.Turbine 7:Other HP '5- Pump Set--I r 7 ft Standing Water Level 104e 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 <br /> - <br /> SIGNED .2:��2�� TITLE /f-1/� DATE <br /> I I I <br /> I <br /> .EENT <br /> I II VED <br /> 4 2010 <br /> II R TA NTy <br /> HENT <br /> 4� I <br /> ---91 <br /> i <br /> i <br /> DEPARTMENT USE ONLY <br /> Application Accepted By �r� L Date 7 d9 a1J''0 Area tsf Employee ID# I <br /> Grout Inspection By Date 0 PECIAL Well Permit <br /> Pump Inspection By � �r•,`_� k-�,.1 Date_ I �,11vW D 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 Service Re ues # Invoice# Well ID# <br /> EHD<3.08 8(112019 <br /> WELL 1PUA4P PERMIT <br />