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WELUPUMP 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 /> JOBADDRESS 6230 Mac Farland CTTY2IP Stockton 95212 <br /> in <br /> Fernwood AvP a <br /> CROSS STREET APN n 8 6 S 2A 94 PARCEL SIZE ' - o LAND USE APPLICATION# o <br /> A <br /> OWNERNAME Gloria Schroeder PH0409 931 9011 N <br /> OWNERADDRESS 6230 Mac Farland CITY/STATE/LPStockton,CA 95212 <br /> CONTRACTOR Purviance Drillers, INC PHONE209-887-3554 <br /> CONTRACTOR ADDRESS P.O. BOX 64 CITY/STATE21PLinden CA 95236 <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP <br /> LICENSE X C57 C-61 D-09 Other NUMBER 377923 EXPIRATION DATE 7/3 1/2 1 <br /> BILLING PARTY: ::OWNER CONTRACTOR SUBCONTRACTOWCONSULTANT <br /> DOMESTIC WELL SAMPLING:C General Mineral/Coliform Bacteria(4391)11 Dibromochloropropane(4392)C Arsenic(4393) <br /> INTENDED USE DomeStic/Private [;Irrigation/Agricultural l;Industrial --Water Quality Monitoring C Soil Sampling/Characterization <br /> Public Water System ^ or <br /> ��If different from Owner. Water System Name Contact Name or Ptrone Number <br /> TYPE OF WORK New Well C Replacement Well ;;Well Alterabon/Modification C Other C'1 N <br /> Monitoring Well(s) #ofwells :1 Soil Boring(s) #of borings Geotechnical #or bo ngs L �/ <br /> Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair (+�^ <br /> New Pum Pum Replacement 7 Pum Repair Raise Well CasingSEP 6 2020 <br /> WELL CONSTRUCTION , <br /> Drilling Method -.Mud Rotary Air Rotary _Auger G Cable Tool -i Push Point G Other SAN`/OA IN <br /> Proposed Well Depthft Excavation in diameter ❑Open Bottom �i Gravel Pack/Gravel Size H& D EN CC) <br /> �TY <br /> Conductor Casing in diameter / Conductor Casing Depth ft ART MSNT <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched I i Steel ::Plastic ;i Stainless Steel [1 Other <br /> Grout Seal Depth ft :Neat Cement(94 lb bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) _i Other <br /> Grout Placement Method Pumped Free Fall L Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By -Driller -Pump Contractor L Other <br /> C Concrete Pedestal :Dimensions:Width it Length it Thick in Christy Box Stove Pipe <br /> PUMP " Submersible TurbVe L:Other HP Pump Set ft Standing Water Level 1 b0 ft <br /> 1 HEREBY CERTIFY THAT 1 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 /> SIGNED it:. r Z.!/L.0 _.cam TITLE :. ATE ,? /I OZQ�U <br /> L <br /> l DEPARTMENT USE ONLY <br /> Application Accepted By 1�� Date �d Jv'- t <br /> Area '1 r Employee ID# I 1' <br /> Grout Inspection By Date I SPECIAL Well Permit <br /> Pump Inspection By Date 4L�i ❑ WAIVER Received <br /> Soil Boring inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permit/Codes Info B ,Cash Remitted Service Reuest# Invoice# Well ID# <br /> EHD 43.06 BH 72019 WELL/PUMP PERMIT <br />