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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.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> ' m <br /> JOB ADDRESS 00 L.It-0 i-+Y' Rd Cn-y0P(:1f mPnts,Ca m <br /> Mr;Ck," I1(�. 00908008 0 <br /> CROSS SAO' APN PARCEL SIZE�'- �' LAND USE APPLICATION# O <br /> _ y <br /> m <br /> OWNER NAME Wa_ttC Vi npya TLjs PHONE �n <br /> OWNER ADDRESS 1()5 1 T.i n r-n I n A vp CITYISTATE/ZIP Lodi Ca 99240 <br /> CONTRACTOR Purviance Drillers, INC PHONE209-887-3554 <br /> CONTRACTOR ADDRESS P-O- Box 64 CrrYI8TATEIZIPL 1IIde1'I CA 95236 <br /> SUBCONTRACTORICONSULTANT PHONE <br /> SUBCONTRACTORICONSULTANT ADDRESS CITY/STATE/7JP <br /> LICENSE C-57 G C-61 ;.D-09 Other NUMBER 3 7 7 9 2 3 EXPIRATION DATE 7/31/21 <br /> BILLING PARTY: -OWNER ;1 CONTRACTOR ;i SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING:G General Mineral/Coliform Bacteria(4391)C Dibromochloropropane(4392)C Arsenic(4393) Y <br /> INTENDED USE Dourest rJPr vale rngation/Agricultural Industrial -Water Quality Monitoring '7 Soil Sampling/Charactenzation M��T <br /> L Public Water System e/ 86 <br /> If different from Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well I:Replacement Well C Well Alteration/Modification ;'Other ' 152020 5 ?020 <br /> (ST <br /> Monitoring Well(s) #of wells ❑Soil Boring #of borings s) ❑Geotechnical 9 of bJ9 <br /> ,I Cut-Of-Service Well C Out-Of-ServiceWell Renewal U Cross Connection Repair N`JQQ(? <br /> New Pum - Pum Replacement Pum Repair L Raise Well CasingyV/f' /N C0UN <br /> WELL CONSTRUCTION _ D MENT-L ry <br /> Drilling Method G Mud Rotary C Air Rotary SI Auger :]Cable Tool L Push Point Other ART MENT <br /> Proposed Well Depth ft Excavation in diameter -I Open Bottom --Gravel Pack/Gravel Size in diameter <br /> -Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched Steel Plastic ;i Stainless Steel C Other <br /> Grout Seal Depth ft ❑Neat Cement(941b bag/S10 gal water) Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) L,Other <br /> Grout Placement Method Pumped :;Free Fall L Other :1 Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller -�Pump Contractor L Other <br /> Concrete Pedestal'_Dimensions:Width ft Length ft Thick in G Christy Box ❑Stove Pipe <br /> PUMP Submersibl " Turbirie Other HP Pump Set 70 ft Standing Water Level fl <br /> 1 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 /> 0 T PS 3Q'ar: <br />