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WELL/PUMP PERMIT <br /> SAN JDAoum COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468-3420 <br /> NON-REFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES'I YEAR FROM DATE ISSUED <br /> to <br /> JOB ADDRESS 3.0,200 >; St Rt 26 Hwy CrrWbpLinden Ca 95236 m <br /> a <br /> CROSS STREET W i m e r R rj APN 66 /�]Z701913 PARCEL SIZE, LAND USE APPLICATION# o <br /> P <br /> m <br /> OWNER NAME ,Tarr ( L)1 nMbini PHONE209-607-71 32 fA� <br /> OWNERADDRESS P -0- BOX 764 CITY/STATE/ZIFLinden CA 95236 <br /> CONTRACTOR Purviance Drillers, INC PHONE209-887-3554 <br /> CONTRACTOR ADDRESS P-O- BOX 64 CITYISTATE21PLi nden CA 95236 <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CnY/STATE/ZIP <br /> LICENSE X C-57 :C-61 _'D-09 ::Other NUMBER 377923 EXPIRATION DATE 7/31/21 <br /> BILLING PARTY: :,OWNER _1 CONTRACTOR C SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:; General Mineral/Coliform Bacteria(4391)[i Dibromochloropropane(4392)G Arsenic(4393) <br /> INTENDED USE Domestic/Private Ir igabon/Agricultural L.Industrial Water Quality Monitoring .;Soil Sampling/Characterization <br /> = Public Water System <br /> If different from Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well -,'Replacement Well Well Alteration/Modification _;Other <br /> Monitoring Wells) #of wells Soil Boring(s) p of bonngs 7 Geotechnical tt of borings <br /> Out-0f-Service Well Out-Of-Service Well Renewal [:Cross-Connection Repair <br /> New Pump Pump Replacement [;Pump Repair a Raise Well Casing <br /> WELL CONSTRUCiION <br /> Drilling Method Mud Rotary Air Rotary r!Auger Cable Tool Push Point J Other <br /> Proposed Well Depth ft Excavation in diameter :l Open Bottom [l 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 D Stainless Steel .l Other <br /> Grout Seal Depth ft :I Neat Cement(94 Ib bag15-10 gat water) _Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) D Other <br /> Grout Placement Method : Pumped _Free Fall [-.-Other C Retardant/Accelerator(name) <br /> PEDESTAL Installed By '- Driller L:Pump Contractor L Other <br /> Concrete Pedestal=Dimensions:Width ft Length ft Thick in I Christy Box ;1 Stove Pipe <br /> PUMP :.Submersible Turbine Other HP Pump Set _ft Standing Water Level /'// ft <br /> I HEREBY CERTIFY THAT I AVE 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 /> 01'07 t1c rn�1 c r ,tcRcnT•_ngr ;-n E s I 120101 nv <br /> _..CE P."_._.. __. .f':...:.�, � ].S fs_:..,.&c C'•.:._. ,.� ,,rte <br /> TITLE --L'r DATE ���i1'�" <br /> I AE FN T <br /> i <br /> VFX <br /> t—0 tpu/N C <br /> l g ?0?0 <br /> ART7-LNTV <br /> MENT <br /> 17 <br /> _7 DEPARTMENT USE ONLY Lt <br /> Application Accepted By ��r Date ��7 �Jy Area I e/! Employee ID# <br /> Grout Inspection By Date 11 SPECIAL Well Perrnit <br /> Pump Inspection By t'. 16`any w-L:a IXA. Date ;."j r; i7 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Permit/ Invoice# Well ID# <br /> Codes Info Cash Remitted Service Request# <br /> EHD x396 6/11=19 WELL(PUMP PERMIT <br />