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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)4684420 <br /> NON-REFUNDABLE PERMIT www.sigov.org/ohd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS --non --nnri <br /> Cm121P T.i orlon 9526 <br /> IN <br /> CROSS STREET Paul APN 09331002 PARCEL SIZE l b 1 LAND USE APPLICATION# 6 <br /> 0 <br /> OWNER NAME Shelton Rd Ranch LLC <br /> PHONE <br /> OWNER ADDRESS 1R6n- )n T_ha,_.ajDd CITY/STATEM- T.i nr3 -n A 9S 6 <br /> CONTRACTOR Purviance Drillers INC PHONE209-887-3554 <br /> CONTRACTOR ADDRESS P-0. Box 64 CITY/STATEMpLinden CA 95236 <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTORICONSULTANT ADDRESS CITYISTATE/ZIP <br /> LICENSE X C57 G C-61 C,D-09 C Other NUMBER 377923 EXPIRATION DATE 7/31/21 <br /> BILLING PARTY: OWNER C CONTRACTOR ❑SUBCONTRACTOR/CONSULTANT <br /> DoMEsnc WELL SAMPLING:U.General Mineral/Coliform Bacteria(4391)D Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE C DomestiC/P ivate �(Inigation/Agricultural D Industrial C Water Quality Monitoring D Soil Sampling/Characterization <br /> 01 Public Water Syste <br /> If different from Ovmer. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK Z New Well ❑Replacement Well ❑WON Alteration/Modification ❑Other <br /> Monitoring Well(s) #of wells ❑Soil Borin 9 of�n5 <br /> 9a of boon s <br /> 9{s) ❑Geotechnical s <br /> Out-0f-Serviceell !;Out-Of-Service Well Renewal C Cross-Connection Repair PAYN►E <br /> New Pump 12PumpReplacement Pump Re air 0 Raise Well Casi N r <br /> WELL CONSTRUCTION �E/�E <br /> Drilling Method Mud Rotary G Air Rotary O Auger' Cable Tool C Push Point Irl Other D <br /> Proposed Well Depth ft Excavation in diameter LI Open Bottom D Gravel Pack/Gravel Size in diem 0 <br /> C Conductor Casing In diameter / Conductor Casing Depth ft 2020 <br /> Well Casing Diameter_In G ❑Thlckness[Gauge/ASTM Schad Steel Plastic ❑Stainless Steel SI ether Sq <br /> Grout Seal Depth ft G Neat Cement(94 Ib bag/5-10 gel Water) C Sand Cement yak r 9A 0N E�LINTY <br /> ❑Bentonite(20%solids) El Other t <br /> Grout Placement Method G Pumped C Free Fall C C Retardant/Accelerator(name) MOther LT rOEN)EPA <br /> PEDESTAL Installed By C Driller a Pump Contractor C Other <br /> ❑Concrete Pedestal CDimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP Submersibl Turbine ❑Other HP O <br /> Pump Set (�O ft Standing Water Level 2:IL5 <br /> 1 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 /> ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THI AM <br /> CURRENT AND ACTIN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. AT <br /> f'0 ii LCE RFQUiRED FO INSp ^T30NS-PLEASE CALL(2.OS1 Sr?.7.t;o-;,,1 <br /> SIGNETrnmTLE <br /> DATE 7- <br /> -------T -------------------- <br /> - I r—————————————————— -4 <br /> DEPARTMENT U E 9NLY n <br /> Application Accepted By �` � Date /00 1//�� Area Employee ID# F" <br /> Grout Inspection By Date —It <br /> CIAL Well Permit <br /> Pump Inspection By Data G 61 -1 WAIVER Received <br /> Soil COMMENTS Boring Inspection By ti Date Constructed Well Depth {t <br /> PE <br /> Codes Inco Received Codes <br /> 74 ourrt Date PermW <br /> Cash Remitted Service Re u # In <br /> '4391 <br /> Well IN <br /> � o SO W <br /> EHDasas entrzois �Y2--71 <br /> WELL(PUMP PERMIT <br />