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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1668 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)4683420 <br /> NON-REFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 6370 E. Waterloo Rd (- Sr ZT &Tr4jj) CnY/LP_Stockton, 95215 m <br /> D <br /> CROSS STREET White Lane APN1 01-090-09 PARCELSIZE LAND USE APPLICATION# o <br /> A <br /> m <br /> OWNER NAME Aa West , INC PHONE 209-479-3999 H <br /> OWNERADDRESS P-17- BOX 739 CITY/STATFIZIPLlnden CA 95236 <br /> CONTRACTOR Purviance Drillers, INC PHONE209-887-3554 <br /> CONTRACTOR ADDRESS P.0- BOX 64 CITYISTATE ZIPLi nden CA 95236 <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITYISTATEIZIP <br /> LICENSE X C-57 C-61 .:D-09 :Other NUMBER 377923 EXPIRATION DATE 7/31/21 <br /> BILLING PARTY: __OWNER ;:CONTRACTOR _i SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:C General Mineral/Coliform Bacteria(4391)i Dibromochloropropane(4392)F;Arsenic(4393) <br /> INTENDED USE C Domestic/private Irrigation/Agricultural ::Industrial E Water Quality Monitoring [;Soil Sampling/Characterization <br /> Public Water System <br /> If dMerent from Owner. Water System Name Contact Name or Phone Number <br /> TYPE Or:WORK 7 New Well F Replacement Well -.Well Alteration/Modification ,-i Other <br /> Monitoring Well(s) #of wells _Soil Boring(s) #of borings Geotechnical of borings <br /> Out-Of-Service Well L 0 t-Of-Service Well Renewal Cross-Connection Repair <br /> New Pum Pum Re laceme it um Re air Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary AugerCable Tool Push Point I Other <br /> Proposed Well Depth ft Excavation in diameter l Open Bottom ;7 Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter I Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad C Steel C'Plastic ,Stainless Steel .1 Other <br /> Grout Seal Depth ft Neat Cement(94 Ib bagl5-10 gal water) f]Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) L Other <br /> Grout Placement Method "Pumped--. Free Fall C Other "Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller C Pump Contractor L Other <br /> Concrete Pedestal-Dimensions:Width ft Length ft Thick n F Christy Box Stove Pipe <br /> PUMP 7 Submersible Turbine Other HP Pump Set__4LFV 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 COMPENSATION LAWS. <br /> r`!O'[?a;F T?�Clf lr^'r?�7.0"' r.?C_'^- <br /> .`�C /-tPn,YS '..F/'_,t.r- ALl rnt.�.1r�<, q_,rr.,7 ` <br /> SIGNED\-...y ..!/-'�F TITLE (.f/ i�.SGC/✓-�.G�., - DATE <br /> 2 <br /> gYNjENT <br /> cEl QED <br /> 9 ?020 <br /> q 4�l <br /> N <br /> I ' ' E ARTTA NTY <br /> t___TIE-# MENT <br /> ITT <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Area Employee ID# <br /> Grout Inspection By Date 1 SPECIAL Well Permit <br /> Pump Inspection By f j li.L T—k i Data 0 ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info Cash Remitted Service Re uest# <br /> 113iy v�0 S,-Z I _3 ' <br /> EHD d3-O6 611112019 WELL/PUMP PERMIT <br /> llz,�z�7�9 <br />