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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)4683420 <br /> NON-REFUNDABLE PERMIT www.sigov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOBADDRESS 17300 E Clem Rd cm.rzjPLinden 95236 Ln <br /> � � m <br /> CROSS STREET Duncan Rd APN 09118011 PARCEL SIZE I -1 LAND USE APPLICATION# p <br /> �j (�i m <br /> OWNER NAME ',�)1.�n{9':Jt7�I PHONE y <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> CONTRACTOR Purviance Drillers, INC PHONE209-887-3554 <br /> CONTRACTOR ADDRESS P.O. BOX 64 CITYISTATFJZPL i nden CA 95236 <br /> SUBCONTRACTORICONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITYISTATE/ZIP <br /> LICENSE k C-57 C-61 ❑D-09 ❑Other NUMBER 377923 EXPIRATION DATE 7/3 1/2 1 <br /> BILLING PARTY: OWNER ❑CONTRACTOR a SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:C General Mineral/Coliform Bacteria(4391)L Dibromochloropropane(4392)G Arsenic(4393) <br /> INTENDED USE DomesfirJPfivate rrigatloNAgricultural ::Indust!al Water Quality Monitoring ❑Soil SampiinglCharacterization <br /> -Public Water Syste <br /> If different from Own . Water System Name Contact Nartw or Ptlone Number <br /> TYPE OF WORK New Well i:Replacement Well C Well Alteration/Modification l Other <br /> MonitoringWell(s) #Of wells ';Soil Borin s �0fb0n «ortwrin s <br /> 9O Geotechnical a <br /> Out-Of-Service Well ;Out-Of-Service Well Renewal ❑Cross-Connection Repair 177;New Pum Pum Re lacement Pum Re air ':Raise Well Casin WELL CONSTRUCTION A'Drilling Method ,Mud Rotary Air Rotary Auger I Cable Tool -Push Point OtherSq V✓ ?O�OProposed Well Depthft Excavation in diameter ❑Open Bottom n Gravel Pack/Gravel Size y'p� CConductor Casing in diameter / Conductor Casing Depth ftWel ��'r7 /��o(Nry <br /> Gr Casing Diameter_in Thickness/Gauge/ASTM Sched :Steel ;7 Plastic -Stainless Steel �Other <br /> Grout Seal Depth ft Neat Cement(94 Ib bag15-10 gal water) ❑Sand Cement sack mix/7 gal water E^/T <br /> ::Bentonite(20%solids) Li Other <br /> Grout Placement Method Pumped a Free Fall r:Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By �Driller C Pump Contractor L' Other <br /> Concrete Pedestal Dimensions:Width ft Length ft Thick in Christy Box C Stove Pipe <br /> PUMP :Submersible turbine ;i Other HP Pump Set N StandingWater Level1 I ty <br /> It <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 /> ��.��L _GASB CALL.(<: C� <br /> SIGNED TITLE �"`"`� DATE <br /> y <br /> /DEPARTMENT USE <br /> � -ONLY <br /> Application Accepted By_ "� Date U Area i� �i�i Employee ID# f br' <br /> Grout Inspection By Date J SPECIAL Well Permit <br /> Pump Inspection By t; ;,SJR ls;- ;ti 1 AA 1 Date F11�Q �T1p !7 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date PermitJ <br /> Codes Info Cash emitted Service Re ue # Invoice# Well ID# <br /> EHD 6306 6/71!2(119 WELL/PUMP PERMIT <br />