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WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205.6232(209)4683420 <br /> NON-REFUNDABLE PERMIT www.sl-qov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 12601 N Clements Rd CrrYILP Linden, 95236 <br /> m <br /> CROSS STREET Harney Lane APN C2[rC1r � c <br /> 1.� �1� O�� PARCEL SIZE LAND USE APPLICATION# c <br /> OWNER NAME Alida Smit PHONE 925 324 3444 H <br /> N <br /> OWNER ADDRESS 12601 N Clements Rd Cm/STATErzIP Linden,Ca 95236 <br /> CONTRACTOR Purviance Drillers INCPHONE209'887-3SS4 <br /> CONTRACTOR ADDRESS P-0- Box 64 CrrY/STATEMPL i nden CA 95236 <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOPJCONSULTANT ADDRESS CITY/STATE/ZIP <br /> LICENSE � C-57 C-61 :'.D-09 _:Other NUMBER 377923 EXPIRATION DATE 7/3 1/2 1 <br /> BILLING PARTY: „OWNER CONTRACTOR C SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:C General Mineral/Coliform Bacteria(4391)„Dibromochioropropane(4392)E Arsenic(4393) <br /> C industrial =Water Quality Monitoring !7 Soil Sampling/Charactenzation <br /> INTENDED USE Domestic/Private := Irrigation/Agricultural <br /> Public Water System Nj N T <br /> If different from Omer. Water System Name <br /> wnContact Name a Phom Number 1, <br /> TYPE OF WORK .:New Well ^Replacement Well Well Alteration/Modification ;Other <br /> Monitoring Well(s) #of wells ::Soil Boring(S) #of borings If of bo'm <br /> i]Geotechnical gs <br /> Out-Of-Service Well _Out-Of-Service Well Renewal Cross-Connection Repair AUG-3 12020 <br /> :1 New Pump 2-!LPump Replacement '_Pump Repair Raise Well CasingS <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary -:Air Rotary :Auger Cable Tool ::Push Point ' Other EN�/R ti/ CO <br /> HE MENTA NTY <br /> Proposed Well Depth ft Etcavabon in diameter .1 Open Bottom 7 Gravel Pack/Gravel Size in diameter A <br /> 'Conductor Casing in diameter ! Conductor Casing Depth ft P R TMENT <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched Steel ;;Plastic 71 Stainless Steel ;I Other <br /> Grout Seai Depth ft 7 Neat Cement(94 Ib bag/5-10 gal water) 'Sand Cement sack mixr7 gal water <br /> Bentonite(20%solids) ❑Other <br /> Grout Placement Method -:Pumped L Free Fall r Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By -Driller Pump Contractor 2 Other <br /> ':Concrete Pedestal':Dimensions:Width ft Length it Thick in L Christy Box n Stove Pipe <br /> PUMP Submersible::Turbine C Other HPPump Set —�ft Standing Water Level g <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> LICENSE IS <br /> WORKERS COMPENSATION LAWS. <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY R <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT IAM IN COMPLIANCE WITH ALL <br /> ;w Otirc ADVANCE NOTICE REQt1IREn FOR nt FA.Se <br /> SIGNED \ ':� - <br /> TITLE DATE-------------- <br /> gfa�1� <br /> --------------- <br /> DEPARTMENT��USE,)ONLY <br /> Application Accepted By � �L Date C 3f' P�d'-� Area C��� 1 <br /> Employee ID# <br /> Grout Inspection By Dale ;] SPECIAL Well Perrnit <br /> Pump inspection By Y:y(p s ti'y Date `itisl�'� -1 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Check#/ Amount Permit/ <br /> Codes Info Bydn gash Remitted Da a Service Re uest# Invoice# Well ID# <br /> Ilse 1, J 477 <br /> EHO43-06 611V2019 <br /> 1132716 WELL/PUMP PERMIT <br />