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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468J420 <br /> NON-REFUNDABLE PERMIT www.sigov.org/ohd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOBADDRESS 22880 N. Dustin Rd CITY/ZIP Acampo, 95220 'n <br /> m7 <br /> r� D <br /> CROSS STREET Peltier Rd APN D O-1 OS(7 u\T7 PARCEL SIZE LAND USE APPLICATION# p <br /> OWNER NAME Gabe Subry PHONE 209 747 3457 N <br /> OWNERADDRESS 22880 N Dustin Rd Ctrr/STATE/ZIP Acampo, Ca 95220 <br /> CONTRACTOR Purviance Drillers, INC PHONE209-887-3554 <br /> CONTRACTOR ADDRESS P.O. BOX 64 CITY/STATEIZPLlnden CA 95236 <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP <br /> LICENSE X C-57 J Cfit D-09 i Other NUMBER 377923 EXPIRATION DATE 7/31/21 <br /> BILLING PARTY: OWNER L.CONTRACTOR ;.i SuacoNTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:C General Mineral/Coliform Bacteria(4391)-1 Dibromochloropropane(4392)C Arsenic(4393) <br /> INTENDED USE (DomesticlPrivate _ Irrigation/Agricultural 1 Industrial -:Water Quality Monitoring C Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner. Water System Name Contact Name or Phorw Numbor <br /> TYPE OF WORK New Well C Replacement Well D Wen Alteration/Modification Other ��A <br /> Monitoring Well(s) #of wells D Soil Boring(S) #a borings tt of borings <br /> '1 Geotechnical /� <br /> :;Out-Of-Service Well ❑Out-Of�Service Well Renewal LCross-Connection Repair � �O <br /> New Pump XPump Replacement 5 Pump Repair r-Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ;Mud Rotary Air Rotary Auger. C Cable Tool :Push Point Other SAN If' �D?O <br /> Proposed Well Depth_ft Excavation in diameter ;I Open Bottom Gravel Pack/Gravel Size �d tl" C <br /> Conductor Casing in diameter / Conductor Casing Depth ft �T L y�Fp ?Np ANT y <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched 7 Steel i.;Plastic n Stainless Steel '.I Other <br /> Grout Seal Depth ft Neat Cement(94/b bag15.10 gal water) Sand Cement sack mix/7 gal water MFjvr- <br /> Bentonite(20%solids) ❑Other <br /> Grout Placement Method i Pumped G Free Fall H.Other Retardant I Accelerator(name) <br /> PEDESTAL Installed By -�Driller �Pump Contractor C Other <br /> Concrete Pedestal FIDimenslons:Width ft Length R Thick in C Christy Box G Stove Pipe <br /> PUMP Submersible:;Turbine 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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> ( ADVANCE:NOTICE REQUIRED FO? CT�/►pt:S-?LE4SE CALL{2091953-7F9? <br /> SIGNED ta'�`/_'�r�' "�'���� TITLE V'� 't� DATE <br /> 4-�-�a- <br /> 0 <br /> / DEPARTMENT USE ONLY <br /> l �i 1 /' <br /> Application Accepted By —� Z_Z_ Date i/S/ y.�Lt Area �/ CC7 Employee ID# I ' <br /> Grout Inspection By `- Date ` -J SPECIAL Well Permit <br /> Pump Inspection By «L SI �W�+� Date kL 110r C7 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Data Permit/ <br /> Codes Info Cash Remitted Service Request# Invoice# Well ID# <br /> EH043-e8 61112019 WELL/PUMPPERMIT <br />