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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'I YEAR FROM DATE ISSUED <br /> JGsADDREss6794 E Foppiano LncrrrmP Morada 95212 a <br /> M <br /> CROSSSTREET Ashley Ln APN 08718116 <br /> PARCEL SIZE 172�1)LAND USE APPLICATION# O <br /> � / O <br /> OWNERNAM <t,!SS �i'tL.�l��+ j ��:I:Sf- <br /> PHONE <br /> m <br /> OWNERADDRESS` F,7� r,,7F'G: CnY/STATEmPStockton,CA 95212 <br /> CONTRACTOR Purvianca Drillers, INC PHONE209-887-3554 <br /> CONTRACTOR ADDRESS P.O. BOX 64 CITYISTATE/ZIPLlnden CA 95236 <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/LP <br /> LICENSE $C-57 C-61 D-09 Other NUMBER 377923 EXPIRATION DATE 7/31/21 <br /> BILLING PARTY: --OWNER -CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:f i General Mineral/Coliform Bacteria(4391)C Dibromochloropropane(4392)C Arsenic(4393) <br /> INTENDED USE C Domestic/Private ,IrrigatioNAgricultural .;Industrial -Water Quality Monitoring C Soil Sampling/Characterization <br /> Public Water System <br /> If dHfemnt from Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ::New Well C Replacement Well L Well Alteration/Modification Other <br /> Monitoring Wells) #of wells Li Soil Boring(s) #of bongs Geotechnical n of borings <br /> Out-Of-Service Well C Out-Of-Service Well Renewal C;Cross-Connection Repair <br /> New Pump Pump Re lacement XPump Repair Raise Well Casing <br /> WELL CONSTRUCTION I , <br /> Drilling Method -Mud Rotary Air Rotary Auger Cable Tool 7 Push Point : Other <br /> Proposed Well Depth ft Excavation in diameter ]Open Bottom t]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 C Plastic :iStainless Steel ;I Other <br /> Grout Seal Depth ft Neat Cement(94 lb bag/5-10 gal wafer) Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) ❑Other <br /> Grout Placement Method :;Pumped -i Free Fall 11 Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By '-:Driller -Pump Contractor C Other <br /> C Concrete Pedestal_Dimensions:Width ft Length ft Thick in L'Christy Box [ Stove Pipe <br /> PUMP Submersible Turbine :,Other HP O Pump Set '7- O ft Standing Water Level I D I ft <br /> I 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 /> ..K:VvC PLEAS=CALL(209)95,3-769' <br /> SIGNED TITLELplt <br /> DATE <br /> YMENT <br /> CEIVED <br /> ------- <br /> -&T 2 1 2020 <br /> OAQUIN COUNTY <br /> VIRONMENTAL <br /> TH DEPARTMENT <br /> DEPARTMENT USE ONLY r <br /> Application Accepted By /` t Date C' .rte v1y (C� Employee 1 <br /> Area d Em Io ee ID# <br /> Grout Inspection By Date I SPECIAL Well Permit <br /> Pump Inspection By 4 t•r\j,S\•� X21:l 1^ n� Date <br /> y r 1U�� 7 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> r <br /> PE SC Received ck#/ Amount perm <br /> Codes Info Cash Remitted Date ervice Re uest# Invoice# Well ID# <br /> 93F� o 7 _ <br /> EHo4"o 6/112019 <br /> WELL/PUMP PERMIT <br />