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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)4683420 <br /> NON-REFUNDABLE PERMIT www.sigov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOBADDRESS 1 7887 Comstock Rd cryrLp Linden,Ca 95236 <br /> CROSS STREET APN 9//lp Qa 7 n <br /> `\J/(//J(/1�Fi�f J PARCEL SIZE ���. - LAND USE APPLICATION <br /> OWNERNAME Vaccarezza Bros PHONE 209-482-4589 <br /> OWNERADDRESs 8150 N Duncan Rd crrISTATEmPLinden,Ca 95236 <br /> conrrcn=M IPurvianco Drillers, INC PHONE209-887-3554 <br /> CONTRACTOR ADDRESS P-0- BOX 64 CITYISTATEmPLinden CA 95236 <br /> SUBCONTRACTORICONSULTANT PHONE <br /> SUBCONTRACTORICONSULTANT ADDRESS CITY/STATE/ZIP <br /> LICENSE R C-57 C-61 _:D-09 ❑Other NUMBER 377923 EXPIRATION DATE 7/3 1/2 1 <br /> BILLING PARTY: =OWNER J CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:C General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392)G Arsenic(4393) CINTENDED USE Domestic/Private InigatioNAgricultural C Industrial -Water Quality Monitoring C Soil Sampling/Cha cte:_I <br /> C <br /> NT <br /> Public Water System V E D <br /> If different from Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK = New Well C Replacement Well G Well Alteration/Modification D Other 41113-4 <br /> � 1(� 1 n �O�O <br /> Monitoring Well(s) #of wells C Soil BOring(s) #orbonngs D Geotechnical #orbonngs `� <br /> Out-Of-ServiceWeI 0 Out-Of-Service Well Renewal a Cross-Connection Repair <br /> = New Pum um Replacement C Pump Re air _Raise Well SAN JOAQUIN COUNTY <br /> WELL CONSTRUCTION HEALTNTAL <br /> Drilling Method __Mud Rotary Air Rotary �Auger Cable Tool Push Point --- Other H DEPARTMENT <br /> Proposed Well Depth ft Excavation in diameter 7 Open Bottom D Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sahed ::Steel Plastic 7 Stainless Steel t7 Other <br /> Grout Seal Depth ft Neat Cement(94 lb bag/510 gal water) Sand Cement sack mixf7 gal Water <br /> Bentonite(20%solids) D Other <br /> Grout Placement Method C Pumped Free Fall C Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By ::Driller z Pump Contractor C Other <br /> Concrete Pedestal^_Dimensions:Width ft Length ft Thick in Christy Box ❑Stove Pipe <br /> Pu MP _suhmersible C:Turbine Other HP Pump Set ft Standing Water Level '70, ft <br /> I HEREBY CERTIFY THAT 1 HAVE PkEPARED 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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. p <br /> SIGNED / GLL(/LLI�G 'TITLE DATE <br /> I I <br /> I I <br /> I I <br /> I <br /> I I I <br /> I <br /> I <br /> I I <br /> I I I I <br /> I I <br /> I <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Ly Date-g /� dL);U Area r Employee ID# 1 <br /> Grout Inspection By ,tt Date ❑ SPECIAL Well Permit <br /> Pump Inspection By SCf (1c7 Wyy, Date S&I 111111 L ] WAJVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received it/Amount Permit/ <br /> Codes Info By, Cash Remitted ffie Service Request# Invoice# Well ID# <br /> Zb <br /> EM043-M Bn72M9 <br /> Wa1L/PUMP PERMIT <br />