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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.sigov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOBADDRESS 29159 Jacktone Rd CIry/ZtPGalt 95632 Ln <br /> th <br /> CROSS STREET Liberty Rd APIN 00719016 PARCEL SIZE (I i Ci LAND USE APPLICATION# l o <br /> OWNERNAME Blslieri Farms, FLP y <br /> PHONE rn <br /> OWNERADDRESS P.O.BOX 604 CITY/STATE21PClements,CA 95227 <br /> CONTRACTOR Purviance Drillers, INC PHONE209-887-3554 <br /> CONTRACTOR ADDRESS P-O. Box 64 CITY/STATE)ZIPLinden CA 95236 <br /> SU13CONTRACTOPJCONSULTANT PHONE <br /> SUBCONTRACTORICONSULTANT ADDRESS CITY/STATE/ZIP <br /> LICENSE X C-57 C-61 -. D-09 Other NUMBER 377923 ExPIRAmON DATE 7/31/21 <br /> BILLING PARTY: -OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:I:General Mineral/Coliform Bacteria(4391)::Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring I'Soil Sampling/Characterization Y <br /> Public Water Syste <br /> If different from O_' .1 Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well C Replacement Well Well Alteration/Modification Other <br /> -Monitoring Well(s) #of wells =Soil Boring(s) 4 or borings #W bolos D <br /> ' Geotechnical S O <br /> Out-0f-Service Well Out-OfServire Well Renewal '-'.Cross-Connection Rep air <br /> New Pum Pum Replacement Pum Repair Raise Well CasingF JCA U/�/ 020 <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary Air Rotary Auger :.Cable ToolPush Point Other ACTH pq�/V ANT Y <br /> Proposed Well Depth It Excavation in diameter J Open Bottom C Gravel Pack/Gravel Size in diameter TME/vr <br /> :-Conductor Casing in diameter / Conductor Casing Depth It <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched Steel C Plastic Stainless Steel _I 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) Other <br /> Grout Placement Method Pumped ::Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By = Driller Pump Contractor c Other <br /> Concrete Pedestal:.Dimensions:Width ft Length ft Thick in Christy Box Stove Pipe <br /> PUMP :SubmersibleTurbine Other HP_L2E;> Pump Set Lit Standing Water I e I 1 f n e <br /> I HEREBY CERTIFY THAT I AVE 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 /> itiS-"LEASE CALL( <br /> i <br /> SIGNED //�'�� -„ TITLE DATE--------------- <br /> I <br /> ETT �n <br /> I i <br /> I <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date CJ Area Employee ID# / <br /> Grout Inspection By ! Date 1 SPECIAL Well Permit <br /> Pump Inspection By !O[II i,*L Date 7 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Permit/ <br /> Codes Info Cash Remitted ate ll a Request# Invoice# Well ID# <br /> 3 14 iLalk) JA <br /> EHD 43-0e 611 12019 � /� ,/ �� / �/ � WELL!PUMP PERMIT <br />