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WELUPUMP PERMIT <br /> SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205.6232(209)468.3420 <br /> NON-REFUNDABLE PERMIT www.sjgov.org1ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joe ADDRESS <br /> 8401 W Eight Mile Rd CmZPStockton 95219 N <br /> M <br /> ,/' D <br /> CROSS STREET[J R 1 O Blanco APN (//�/J/aap Q`Y� PARCEL SIZE LAND USE APPLICATION# p <br /> T A <br /> OWNERNAME' &A .Solari PHONE ryn <br /> OWNER ADDRESSP•0. BOX 788 c1TY/STATE21Pi�i" nden Ca 95236 <br /> CONTRACTOR Purviance Drillers, INC PHONE209-887-3554 <br /> CONTRACTOR ADDRESS P.0. BOX 64 CITY/STATE21PL i nd en CA 95236 <br /> SuacoNTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTORICONSULTANT ADDRESS CrTY/STATE/ZIP <br /> LICENSE X C-57 L;C-61 D-09 Ll Other NUMBER 377923 EXPIRATION DATE /�y <br /> l31g/ <br /> BILLING PARTY: `!OWNER CONTRACTOR i_1 SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:C General Mineral/Coliform Bacteria(4391)rl Dibromochloropropane(4392)f.Arsenic(4393) <br /> INTENDED USE ')(DomestiC/Private !;Irrigation/Agricultural ;:Industrial '..:Water Quality Monitoring C Soil Sampling/Characterization <br /> Public Water System <br /> If clifferant from Owner. Water System Name Contact Name or Phorre Number <br /> TYPE OF WORK ".New Well C Replacement Well 7:Well Alteration/Modification ,:Other <br /> MonitoringWell(s) #of wells '!SoilBoring(s) #of borings Geotechnical Aofborings <br /> Out-Of-Service Well L�Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pum ump Re lacement C7 Pump Repair C Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ;!Mud Rotary Air Rotary Auger C Cable Tool Push Point : Other <br /> Proposed Well Depth ft Excavation in diameter L Open Bottom Gravel Pack/Gravel Size in diameter <br /> C Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched G Steel E Plastic 'I Stainless Steel 'A Other <br /> Grout Seal Depth it _i Neat Cement(94 lb bag/5-10 gal water) Sand Cement sack mixr7 gal water <br /> Bentonite(20%solids) D Other <br /> Grout Placement Method :: Pumped Free Fall C Other I Retardant/Accelerator(name) <br /> PEDESTAL Installed By E Driller L Pump Contractor L Other <br /> Concrete Pedestal;Dimensions:Width ft Length ft Thick ina Christy Box Stove Pipe <br /> PUMP 2 Submersible:]Turbine :1 Other HP Pump Set It 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 /> VAN CE NO T iCE FRE QJIr E <br /> SIGNED TITLE DATE <br /> i <br /> v <br /> `Y <br /> AN <br /> pqY <br /> 0 <br /> TT <br /> SFO <br /> I >< coq 30��? <br /> t 4y '01 0 <br /> I1 Th�FAq�� <br /> MFtir <br /> # 1 411 1 1 1# <br /> DEPARTMENT USE ONLY <br /> "' <br /> Application Accepted By Date r � JAN Area Employee ID# a <br /> Grout Inspection By Date 1 SPECIAL Well Permit <br /> Pump Inspection By �� 1�[.���, lr�.: l Date 1v l j �i'kti D WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Check#/ Amount Date Pennitl <br /> Codes Info B Cash Remitted S rvice RequestRequest# Invoice# Well ID# <br /> D <br /> FJID 4309 61112019 ` 111717��5 WELL(PUMP PERMIT <br />