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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468-3420 <br /> NON-REFUNDABLE PERMIT www.sigov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 4512 Suburban Rd CrTY/DpStockton CA 95215 m <br /> D <br /> CROSS STREET LEOndrdlnl Rd APN C571 2112 PARCEL SIZE L ) C LANA USE APPLICATION# p <br /> M <br /> OWNER NAME Sonia Martinez PlOIE209-470-9132 <br /> OWNERADDRESS 451 2 Suburban Rd C"STATEILPStockton Ca 9521 5 <br /> CONTRACTOR Purviance Drillers, INC PHONE209-887-3554 <br /> CONTRACTOR ADDRESS P.O. BOX 64 Cm./STATFJZPLinden CA 95236 <br /> SUBCONTRACTORICONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE ZIP <br /> LICENSE R C-57 C:C-61 _!D-09 i'Other NUMBER 377923 EXPIRATION DATE 7/3 1/2 1 <br /> BILLING PARTY: ,_OWNER 'i CONTRACTOR SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING:G General Mineral/Coliform Bacteria(4391)Uj Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE <br /> it DomestiGPrivate C;Imgabon/Agricultural Industrial G Water Quality Monitoring _Soil Sampling/Charactenzation <br /> Public Water System <br /> If different from Owner Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well r-Replacement Well 2 Well Alteration/Modification Other <br /> Monitoring Wells #of wells Soil Boring(s) a of borings -Geotechnical a of w rgs <br /> Out-0f-Service Well _Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ]New Pump S Pump Replacement G Pump Repair Raise Well Casing `` 1, <br /> WELL CONSTRUCTION ViEF <br /> Drilling Method _i Mud Rotary Air Rotary ::Auger C9ble Tool a Push Point Other d <br /> Proposed Well Depth ft Excavation in diameter 11 Open Bottom D Gravel Pack/Gravel Size in diamete 2020 <br /> C Conductor Casing in diameter / Conductor Casing Depth ft ZSA JO,4 <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched ^Steel Plastic ^Stainless Steel :]Other E Q C <br /> Grout Seal Depth ft Neat Cement(94 Ib bag/S10 gel water) ❑Sand Cement sac T�yl &N74 L TY <br /> Bentonite(20%solids) Z)Other RTIl7ENT <br /> Grout Placement Method 7 Pumped ---Free Fall G Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By :Driller L.Pump Contractor L' Other <br /> Concrete Pedestal-Dimensions:Width ft Length ft Thick in C Christy Box C Stove Pipe <br /> IPF-MP I Submersible Turbine –Other HPZ, 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 COMPENSATION LAWS. <br /> 7 FSt( R,AD_kNCE NO T?CF REQ1)1RE70 FOR <br /> INSF CT!ONS-PLrASE C:A!.>, <br /> SIGNED C 2LI04 kc-1— TITLE DATE <br /> "������111111 <br /> I F <br /> 4 <br /> a <br /> I <br /> DEPARTMENT US/E/ ONLY <br /> Application Accepted By jr/ L�� Date Area '✓f' Employee ID# r` <br /> Grout Inspection By _ Date 7 SPECIAL Well Permit <br /> Pump Inspection By_ --r{rV,S ') i rE _t L Date tl l�/1�1c ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Perm <br /> Codes Info sh Remitted Date Service Re uest# Invoice# Well ID# <br /> r1 i 1 <br /> EHD43-06 6/112019 WELL/PUMP PERMIT <br />