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WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)4683420 <br /> NON-REFUNDABLE PERMIT WWW.S Ov.Or /ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 12900 N Clements Rd Cn-vZirinden CA 95236 U/ <br /> / i <br /> CROSS STREETFra s i e r RD APN D6SaoyO 3 PARCEL SIZE 36'10LAND USE APPLICATION# <br /> v <br /> OWNER NAME Lawrence SAmbado PHONF209-969-8077 w <br /> N <br /> OWNER ADDRESSP.O. BOX 461 CITYISTATE/ZIP Linden CA 95236 <br /> CONTRACTOR Purviance Drillers INC PHONE209-887-3554 <br /> CONTRACTOR ADDRESS P-0. BOX 64 CRY/STATE/ZIPL i nden CA 95236 <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTORICONSULTANT ADDRESS CITY/STATEZP <br /> LICENSE $C-57 ._C•61 CI-09 ❑Other NUMBER3 7 7 9 2 3 EXPIRATION DATE <br /> 7/31/21 <br /> BILLING PARTY: -:OWNER 7 CONTRACTOR i SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELLSAMPUNG:( General Mineral/Coliform Bacteria(4391)is Dibromochloropropane(4392)C Arsenic(4393) <br /> INTENDED USE DOmeSUC/Private - IrrigationlAgricultural L Industrial ':Water Quality Monitoring [;Soil Sampling/Characterization <br /> Public Water System <br /> If different from Cwner. Water System Namo Contact Name or Phone Number <br /> TYPE OF WORK New Well i Replacement Well Well Alteration/Modification i Other <br /> Monitoring Well(s) #of wells _SOil BOdng(s) #of borngs =Geotechnical n of borings <br /> Out-Of-Service Well 1 Out-OfService Well Renewal Cross-Connection Repair <br /> 7 New Pump rPump Replacement C;Pump Repair Raise Well Casin <br /> WELL CONSTRUCTION <br /> Drilling Method -:Mud Rotary Air Rotary ;Auger Cable Tool Push Point Other <br /> Proposed Well Depth ft Excavation in diameter I Open Bottom 7.1 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 i'I Stainless Steel .I Other <br /> Grout Seal Depth ft Neat Cement(94 Ib bag15-70 gal water) J Sand Cement <br /> sack mix/7 gal water <br /> Bentonite(20%solids) 7 Other <br /> Grout Placement Method Pumped _:Free Fall L Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By "Driller _Pump Contractor L Other <br /> Concrete Pedestal -Dimensions:Width ft Length it Thick in :Christy Box "Stove Pipe <br /> PUMP ::Submersible- urbine -;Other HP Pump Set _ft Standing Water Level /.�- 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. 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 OMPENSATION LAWS. <br /> nD114t�C�A!('1Tj.^,F R:Q(,'•^cn Z�rtn f ccr' n -,:,+c --r S -' <br /> SIGNED l/TGLTITLE DATE <br /> I <br /> I <br /> N c 4® <br /> I pqR��N TY <br /> I T <br /> DEPARTMENT USE ONLY <br /> J <br /> Application Accepted By Date /,3 <br /> { � Area <br /> pTOn7D EmployeelD#� '� <br /> Grout Inspection By Date I SPECIAL Well Permit <br /> Pump Inspection By T :rt - i t V, Date 2� Y -1 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount pe�W <br /> Codes Info B Cash Remitted Date Service Re u s Invoice# Well ID# <br /> EHD 47-06 6/712019 <br /> //�-2� /y) / 3Y WELL/PUMP PERMIT <br />