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WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468.3420 <br /> NON-REFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOBADDREW17344 E. Frazier Rd CrytZPLinden, 95236 <br /> m <br /> D <br /> CROSSSTREET Clements Rd APN D�S�OO�( PARCEL SIZE?� LAND USE APPLICATION# O <br /> OwNERNAME Paul Wolf Ranch PHONE 915-0663 y <br /> OWNERADDRESS 10070 N. Tully Rd CITY/STATE/7JPLinden, Ca 95236 <br /> CONTRACTOR Purviance Drillers, INC PHONE209-887-3554 <br /> CONTRACTORADDRESSP•O• BOX 64 CITY/STATE/ZIPLinden CA 95236 <br /> SUBCONTRACTORICONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP <br /> LICENSE k C-57 C-61 _D-09 U Other NUMBER 377923 EXPIRATION DATE 7/3 1/2 1 <br /> BILLING PARTY: C:OWNER CONTRACTOR ,7 SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:E General Mineral/Coliform Bacteria(4391)11 Dibromochloropropane(4392)D Arsenic(4393) <br /> INTENDED USE Domestic/Prtvate ❑Irrigation/Agricultural n 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 D New Well i,Replacement Well C Well Alteration/Modification D Other <br /> ❑Monitoring Well(s) #Of wells 7 Soil Boring(s) #of borings n Geotechnical #of borings <br /> U Out-Of-Service Well C Out-Of-Service Well Renewal J Cross-Connection Repair <br /> New Pump Pump Replacement X Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method _Mud Rotary =Air Rotary J Auger Cable Tool ,Push Point C Other Sq N a ,.)0?0 <br /> Proposed Well Depth ft Excavation in diameter tl Open Bottom C Gravel Pack/Gravel Size irl tL+ C <br /> p(/ <br /> Conductor Casing in diameter / Conductor Casing Depth ft �/ <br /> p� Ht NTy <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad :Steel ;]Plastic :]Stainless Steel J Other <br /> Grout Seal Depth ft Neat Cement(94/b bag/S-10 gal water) ❑Sand Cement sack mix/7 gal water -4;- <br /> Bentonite(20%solids) 3 Other <br /> Grout Placement Method C: Pumped -Free Fall L Other Retardant!Accelerator(name) <br /> PEDESTAL Installed By :Driller L Pump Contractor C Other <br /> C Concrete Pedestal 7Dimensions:Width ft Length ft Thick in :,Christy Box 7 Stove Pipe <br /> PUMP Submersible;:Turbine :7 Other HP . 5- Set -10 <br /> Pump ft Standing Water Level I&Y 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 /> z.. =�-,.`"2FJ FC °:-.P TIONS-_^: .'.AS=CALL(23°) <br /> SIGNED�//M ��(,(�f.(l�•d 1-Gx- TRLE ti�� �i't�0i4n DATE`7 •�•^-a <br /> Hf r <br /> El <br /> DEPARTMENT USE ONLY ( [ <br /> Application Accepted Byi Date Area ��' %G Employee ID# <br /> Grout Inspection Inspection By Date J SPECIAL Well Permit <br /> Pump Inspection By-1,k: ,.1 <br /> Date In 11,4 _ ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Permit <br /> Codes Info ev,- Cash Remitted Date Service R u t# Invoice# Well ID# <br /> -17 <br /> EHD 43-06 6/11/2019 � /���, /��� WELL/PUMP PERMIT <br />