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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-0232(209)468-3420 <br /> NON-REFUNDABLE PERMIT www.sigov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOBADDRESS 20799 Comstock Rd CrTY21P Linden, 95236 m <br /> D <br /> CROSS STREET De m a r f i n i T n APN 09132009 PARCEL SIZE P. LAND USE APPLICATION# o <br /> OWNER NAME I_Sherrie_Genetti _z PHONE y <br /> OWNER ADOREss _9942 E Copperopolis RD clrnsraTErzIP Stockton C 25215 <br /> CONTRACTOR Furvianca Drillers, INC PHONE209-887-3554 <br /> CONTRACTOR ADDRESS P.O. BOX 64 CITY/STATE21PLi nden CA 95236 <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CIN/STATE21P <br /> LICENSE )�C-57 ]C-61 :7 D-09 Other NUMBER 377923 EXPIRATION DATE 7/31 21 <br /> BILLING PARTY: OWNER =CONTRACTOR !'. SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:[i General Mineral/Coliform Bacteria(4391)-1 Dibromochloropropane(4392)L Arsenic(4393) <br /> INTENDED USE Domestic/Private Irrigation/Agricultural ;] Industrial Water Quality Monitoring Soil SamplinglCharacterization C.I <br /> C Public Water System VI v <br /> If different from Owren Water System Name Contact Name or Phone Number rD <br /> TYPE OF WORK ❑New Well C Replacement Well ❑Well Alteration/Modification (,Other C <br /> ❑Monitoring Well(s) #ofwells Ci Soil Borings) #Ofbodngs _:Geotechnical #of borings O O 2020 <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cl Cross-Connection Repair <br /> New Pum L Pump Replacement AYPump Repair aj4z,4L -Raise Well Casing SAN J�q <br /> WELL CONSTRUCTION [� N CQ <br /> UN <br /> Drilling Method 7 Mud Rotary Air Rotary Auger C Cable Tool :1 Push Point is Other HEALTH p RTM L ry <br /> Proposed Well Depth ft Excavation in diameter ❑Open Bottom -'Gravel Pack/Gravel Size in diameter ENT <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched [:Steel ❑Plastic J Stainless Steel .I Other <br /> Grout Seal Depth ft - Neat Cement(94/b bag/5-10 gal water) Sand Cement sack mix/7 gal Water <br /> C Bentonite(20%solids) ❑Other <br /> Grout Placement Method _Pumped -Free Fall f1 Other =: Retardant/Accelerator(name) <br /> PEDESTAL Installed By _Driller C Pump Contractor L Other <br /> L2 Concrete Pedestal:]Dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP C Submersible Turbine' 2 Other - HP Pump Set +''90 ft Standing Water Level l7C� ^ 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 /> SIGNED <br /> TITLE r,I dL..o,.. DATE <br /> L^ <br /> I <br /> . r r . <br /> I <br /> � i U <br /> i <br /> I I <br /> / DEPARTMENT USE NLY <br /> Application Accepted By CL—� Date aJ�iJ Area Employee ID# f r <br /> Grout Inspection By Date 11 SPECIAL Well Permit <br /> Pump Inspection By '�p.r�t,5 Cti (; „� ; t— Date Lw 'r' ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC RecelVed Check#/ Amount Permit/ <br /> Codes Info Date <br /> Cash Remitted Service Re!u st# Invoice# Well ID# <br /> X­ '77- 1i iG <br /> EHD 43-06 6/112019 ( / ��7 <br /> T 7/ ` ?V WELL!PUMP PERMIT <br />