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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232 (209)4683420 <br /> NON-REFUNDABLE PERMIT www.sigov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 5151 ST RT 99 (F ontacle Rd) Cm17rP Stockton 95212 m <br /> D <br /> CROSS STR Hammer Lane APN 1 3 0 0 4 018 PARCEL SIZE LAND USE APPLICATION# o <br /> a <br /> OWNERNAME David Blanchard PHONE209 406-4728 H <br /> OWNERADDRESS 1 1 651 E. Eight Mile Rd CfTY/STATEfZIP Stockton, Ca 95212 <br /> CONTRACTOR Purviance Drillers, INC PHONE209-887-3554 <br /> CONTRACTOR ADDRESS P.O. BOX 64 Cm/STATE/ZIPLinden CA 95236 <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTORICONSULTANT ADDRESS CITY/STATE/ZIP <br /> LICENSE X C-57 C-61 - D-09 Other NUMBER 377923 EXPIRATION DATE 7/3 1 /2 1 <br /> BILLING PARTY: OWNER .:CONTRACTOR 7 SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:,,-General Mineral/Coliform Bacteria(4391).7 Dibromochloropropane(4392)C Arsenic(4393) <br /> INTENDED USE Domestic/Private ::Irrigation/Agricultural .: Industrial 'Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If different fmm Owner: Water System Name Contac Name or Phone Number cy� <br /> TYPE OF WORK New Well i Replacement Well :Well Alteration/Modification -I Other <br /> = <br /> Monitoring Well s #of wells Soii Borin9s #of borings "Geotechnical #of borings <br /> J <br /> Out-Of-Service Weil Out-Of-Service Well Renewal 1i Crass-Connection Repair <br /> New Pump C Pump Replacement Xpump Repair _Raise Well Casing7 <br /> WELL CONSTRUCTION �O <br /> Drilling Method Mud Rotary 17 Air Rotary Auger : Cable Tool �Push Point III Other L H FNV/R Q C <br /> Proposed Well Depth ft Excavation in diameter -i Open Bottom Gravel Pack/Gravel Size n i FNO�Njy <br /> Conductor Casing in diameter 1 Conductor Casing Depth ft R jM�NT <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched : Steel ::Plastic :Stainless Steel I Other <br /> Grout Seal Depth ft Neat Cement(94 Ib bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> -Bentonite(20%solids) D Other <br /> Grout Placement Method Pumped Free Fall I i Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller _Pump Contractor L Other <br /> _Concrete Pedestal -Dimensions:Width ft Length It Thick in G Christy Box Stove Pipe <br /> ------------ <br /> ��E UMP )(Submersible. Turbirie Other HP Pump Set 7 ft Standing Water Level'E 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 /> 'ANCE NOT[Cc R lSr C'i ,QS-PLEASE CA'.. <br /> SIGNED TILE TILE (t✓��' �'✓�^ %$ DATE �r <br /> e r <br /> #H <br /> I <br /> 1 <br /> I <br /> Q <br /> DEPARTMENT USE ONLY <br /> i <br /> Application Accepted By ����- Date e' f %✓O Area Employee ID# <br /> Grout Inspection By ( Date y SPECIAL Well Permit <br /> Pump Inspection By Ci 2��,5\.� Lo�l'lc Z.- kip Date 1 lL,A% i WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permit! Invoice# Well ID# <br /> Codes Info Cash Remitted Service Re uest# <br /> 477 1WN,04161L <br /> EHD 43-06 6H1/2019 � � �1,�. �T�� <br /> .�h`, // WELL/PUMP PERMI' <br />