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WELL/PUMP 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 /> JOBADDRESS 5524 Duncan Rd crrYlzlP Linden,Ca 95236 T <br /> m <br /> D <br /> r r <br /> CROSS STREET Monte VistaAPN og(aRooa- PARCEL SIZE ': LAND USE APPLICATION# p <br /> OWNER NAME Patrick McTighe PHONE209 470-1195 N <br /> m <br /> OWNERADDRESS1790 Verdi Canyon Rd Cm/BTATEIMPArroyo Grande,CA 93420 <br /> CONTRACTOR Purviance Drillers, INC PHONE209-887-3554 <br /> CONTRACTOR ADDRESS P•0• Box 64 CITYISTATERIPLi nden CA 95236 <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTORICONSULTANT ADDRESS CITY/STATEIZIP <br /> LICENSE R C-57 ❑C-61 C D-09 ❑Other NUMBER 377923 EXPIRATION DATE 7/31/21 <br /> BILLING PARTY: Ci OWNER i;CONTRACTOR SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING:C General Mineral/Coliform Bacteria(4391)G Dibromochloropropane(4392)C Arsenic(4393) <br /> INTENDED USE Domestic/Private . rrigabon/Agdcultural C Industrial r Water Quality Monitoring ❑Soil Sampling/Character nation <br /> Public Water System <br /> If different from Owner Water System Name Contact Name or Phone Number PA <br /> TYPE OF WORK G New Well I'.Replacement Well ❑Well Alteration/Modification C Other <br /> w/ <br /> C Monitoring Wells) #of wells ❑ gof burin <br /> '-,Soil Borin <br /> s) 8s ❑Geotechnical a of borings F`. <br /> -1 Out-Of-Service Well C Out4XService Well Renewal ❑Cross-Connection Repair D <br /> 7 New Pump -25t?ump Replacement C Pump Repair C Raise Well Casing ��� <br /> WELL CONSTRUCTION 5 2020 <br /> Drilling Method Mud Rotary Air Rotary G Auger Cable Tool L.Push Point r7 Other <br /> Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size indl}amet�T �AQLJ� <br /> 11 Conductor Casing in diameter / Conductor Casing Depth ft NEV/R�N�Co�lIUT y <br /> Well Casing Diameter in Thickness/Gauge/ASTM Schad Steel -.Plastic :1 Stainless Steel 7 q Other TN De RT L <br /> Grout Seal Depth ft 11 Neat Cement(94 lb bag/S10 gal water) r!Sand Cement sack mix/7 gal water ENT <br /> C Bentonite(20%solids) ❑Other <br /> Grout Placement Method _:Pumped Free Fall L Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By =Driller r_Pump Contractor L Other <br /> Concrete Pedestal:':Dimensions:Width ft Length ft Thick in C Christy Box G Stove Pipe <br /> PUMP Submersible Turbirie 71 Other HP CC2Pump Set q ft Standing Water Level k to ft <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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS <br /> SIGNED %�rtiC.�-�. i�i'�' 1'['�C TITLE <br /> DATE % /�- <br /> I <br /> f1E ----- <br /> I <br /> (T I I 1 '1111 1 WE <br /> J .rt O <br /> ff I I FET-177 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Data /v �J� Area (f Employee ID# 1 <br /> Grout Inspection By Date �r D iJ SPECIALWell Permit <br /> Pump Inspection Byt-r11 ;, E 'LLt- Date Li 'l WAIVER R@C@IV@d <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Permit/ <br /> Codes Info /Cash Remitted Date ervice Re uest# Invoice# Well ID# <br /> 3Y r v 4 J ti <br /> EHD 43-06 6/77/1079 /W WELL(PUMPPFRMIT <br />