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WELUPUMP 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 1 g2((1-1F F.;gh/tJ�Mi 1 P Rr7 �7 Cm21P Linden,CA 95236 <br /> CROSS STREET yr(.(��(TJL� /u( /PN_alp,h v 7!/�U I D <br /> PARCEL SIZE _ LAND USE APPLICATION# p <br /> OWNLRNAME MIKE HYSKE PHONE 209-482-2105 y <br /> OWNER ADDRESS ]471F Right M 1Rd CITY/STATE/LP Li nden,CA 95236 <br /> CONTRACTOR Purviance Drillers, INC PHONE209-887-3554 <br /> CONTRACTOR ADDRESS P.O. Box 64 CITY/STATEMPLinden CA 95236 <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOWCONSULTANT ADDRESS CITY/STATE/ZIP <br /> LICENSE X C-57 _C-61 ❑D-09 Other NUMBER 377923 EXPIRATION DATE 7/31/21 <br /> BILLING PARTY: I I-OWNER =CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:G General MinerallColiform Bacteria(4391)• Dibromochloropropane(4392)C Arsenic(4393) <br /> INTENDED USE I Domestic/Private E Irrigation/Agricultural G Industrial --Water Quality Monitoring -Soil Sampling/Characterization <br /> Public Water System <br /> Irdifierent from Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well --Replacement Well _Well Alteration/Modification L Other <br /> --Monitoring Well(s) #OfwellS 7SOiiBorings) #Of borings Geotechnical Corborings <br /> --Out-Of-Service Well --Out-Of-Service Well Renewal C Cross-Connection Repair <br /> New Pum um Re lacement Pum Re air -Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method =Mud Rotary Air Rotary Auger Cable Tool Push Point C Other <br /> Proposed Well Depth ft Excavation in diameter -I Open Bottom L7 Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad G Steel ❑Plastic D Stainless Steel ❑Other <br /> Grout Seal Depth ft Neat Cement(94 lb bag/5-10 gal water) D Sand Cement sack mixr7 gal water <br /> G Bentonite(20%solids) 7 Other <br /> Grout Placement Method --Pumped --Free Fall ❑Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By _Driller C Pump Contractor C Other <br /> C Concrete Pedestal--Dimensions:Width ft Length ft Thick In G Christy Box Stove Pipd <br /> PUMP Submersible❑Turbine G Other HP Pump Set ft Standing Water Level g <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 /> SIGNE /J r <br /> TITLE DATE /�6 <br /> ! I i <br /> I <br /> 77 <br /> I <br /> I � <br /> i <br /> yam/ DEPARTMENT USE ONLY <br /> Application Accepted By oc [_- Date �0�0 Area Employee lD# <br /> Grout Inspection By Date p J SPECIAL Well Permit <br /> Pump inspection By Iw S; /1 �i Date 0�2 7/1, i- 0 WAIVER Received <br /> Soo Boring Inspection By Date Constructed Well Depth R <br /> COMMENTS <br /> PE SC Received ChacldJl Amount <br /> Codes InfoDate Permit/ <br /> Cash Remitted Service R uest# Invoice# Well ID# <br /> END43-M 6h1=9 _) <br /> • // / / �� WELL/PUMP PERMIT <br />