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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 /> JOB ADDRESS 80-11`{ 00O 'I-On Ra �ryry� Crrr/ZIPL I n d e n,C a m <br /> CROSS STREET( C'nST V <br /> R d APN "i 13a D PARCEL SIZE LAND USE APPLICATION# o <br /> D <br /> m <br /> OWNER NAME DPhhv ROSS PHoNE209 887 2382 N <br /> OWNERADDRESS 8031 Hr)nSt-nn Rd CRYISTATEMP Linden,Ca 05236 <br /> CONTRACTOR Purviance Drillers, INC PHONE209-887-3554 <br /> CONTRACTOR ADDRESS P.O. Box 64 CITY/STATEOPLlnden CA 95236 <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTORICONSULTANT ADDRESS CITY/STATFJLP <br /> LICENSE X C-57 C-61 D-09 Other NUMBER 377923 E,,mATION DATE 7/31/21 <br /> BILLING PARTY: -OWNER ,'i CONTRACTOR ❑ SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:G General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392)G Arsenic(4393) <br /> INTENDED USE DOmeStic/Private G InigatioNAgricultural -Industrial C Water Quality Monitoring G Soil Sampling/Characterization <br /> L Public Water System <br /> N Qlffemnt from Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well i'Replacement Well 7 Well AReratioNModification C Other <br /> MonitoringWell(s) #of wells 7 Soil Boring(s) *ofborings iGeotechnical of borings <br /> G Out-Of-Service Well -Out-Of-Service Well Renewal a Cross-Connection Repair <br /> New Pump )QPump Replacement ^Pump Repair C Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary C Auger "Cable Toot Push Point ,' Other <br /> Proposed Well Depth ft Excavation in diameter a 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 Schad ;Steel C:Plastic 11 Stainless Steel i I Other <br /> Grout Seal Depth ft 3 Neat Cement(94 lb bag/5r10 gal water) n Sand Cement Sack mix77 gal water <br /> u Bentonite(20%solids) D Other <br /> Grout Placement Method L'Pumped G Free Fall U Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller L,Pump Contractor L Other <br /> J Concrete Pedestal Ci Dimensions:Width It Length It Thick in G Christy Box G Stove Pipe <br /> PUMP Submersible[!Turbkie ;l Other HP C5 Pump Set ft Standing Water Level 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 I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> rE NOTICE REOtlIREO FO -INS TIONS-PLEASE C. ;;09}953-7� <br /> SIGNEDIL <br /> ? .J.LGZLTI.ZC.G� TE + DATE <br /> If <br /> PAY <br /> REC <br /> SEP - / <br /> Y <br /> SAN ENVIR JOA <br /> CUMN <br /> M1 <br /> M <br /> HEALTH <br /> I <br /> DEPARTMENT U1S� ONLY 1 <br /> Application Accepted By ''ya' l_ Dat.. /7 a�r�d Area / C Employee IDiI f A` <br /> Grout Inspection By Date 11 SPECIAL Well Permit <br /> Pump Inspection By 4r %c. ilL-- Date 1�7�1Q1u1 ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount PerRtit/ Invoice# WeIIID# <br /> Codes Info B Cash Remitted Date Service Re uest# <br /> y I 0 J / .142vJ4 604- 52- <br /> r <br /> END43-M 8111/2019 Mi <br /> 7 Q�/ (Jr�Q/D <br /> (/ WELL(PUMP PERMIT <br />