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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.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 610 N Dietrich Rd clryrzlP minden 95236 m <br /> } D <br /> CROSS STREET E Milton APN i O-> LI CI PARCEL SIZE-S+17 LAND USE APPLICATION# O <br /> M <br /> OWNER NAME Brian Stuhmer pHONE2 0 9-4 8 2-4 4 8 6 y <br /> OWNER ADDRESS 610 N Dietrich RD CITY/STATE/ZP7 inden CA 95236 <br /> CONTRACTOR Purviance Drillers, INC p,ONE209-887-3554 <br /> CONTRACTOR ADDRESS P-0- BOX 64 CITYISTATEIZIPL i nde n CA 95236 <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOWCONSULTANT ADDRESS CITYISTATEIZIP <br /> LICENSE X C-57 Ll C-61 .D-09 -1 Other NUMBER 377923 EXPIRATION DATE 7/31/21 <br /> BILLING PARTY; OWNER CONTRACTOR SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING:G General MineraUColiform Bacteria(4391)C Dibromochloropropane(4392)C Arsenic(4393) <br /> INTENDED USE t DomestidPriO—er ��Water <br /> , Industrial Water Quality Monitoring U Soil Sampling/Characterization <br /> 7 Public Water <br /> i(different from System Name Contact Name or Phone Number <br /> TYPE OF WORK C New Well _Replacement Well ❑Well Alteration/Modification ;:]Other <br /> D Monitoring Well(s) #of wells D Soil Boring(s) #Of borings Geotechnical #of borings <br /> ❑Out-Of-Service Well Out-Of-Service Well Renewal 5 Cross-Connection Repair <br /> ::New Pump 16 Pump Replacement Pump Repair C Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method C!Mud Rotary -Air Rotary !:Auger n Cable Tool - Push Point _ Other <br /> Proposed Well Depth ft Excavation in diameter 'I Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched Steel Plastic ❑Stainless Steel [I Other <br /> Grout Seal Depth ft _Neat Cement(94/b bag/5-10 gal water) C Sand Cement sack mixi7 gal water <br /> C Bentonite(20%solids) ❑Other <br /> Grout Placement Method -- Pumped -Free Fall C Other ;: Retardant/Accelerator(name) <br /> PEDESTAL Installed By _Driller L Pump Contractor L Other <br /> C Concrete Pedestal-Dimensions:Width It Length ft Thick in C Christy Box fl Stove Pipe <br /> (PUMP 2 Submersible'Turbine ❑Other. HP Pump Set ft Standing Water Level ILI-) <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 /> lnA rvc rjf` r -.n p "rites' <br /> CALL(2031 <br /> SIGNED .a c� TITLE - .` DATE / <br /> pA <br /> F F FMT <br /> o <br /> h lQ MRCT�q�NTY <br /> T MENT <br /> l DEPARTMENT <br /> JUSE ONLY <br /> Application Accepted By .�- 1,1` Date 7 �"b0l;tO Area 1 Employee ID# <br /> Grout Inspection By Date 11 SPECIAL Well Permit <br /> Pump Inspection By_ tr n:.`w�dr ,'G'c �wb Date L i`Z: t-1 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received ChecldN Amount PermiU <br /> Codes Info RQI Cash Remitted Date Service Request# Invoice# Well ID# <br /> EHD 43-06 61111l2019 WELL!PUMP PERMIT <br />