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r L <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205.8232(209)468-3820 <br /> NON-REFUNDABLE PERMIT wwwAqov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS Clements Rd c,Tyjzip Linden,CA 95236 <br /> r t-1i <br /> CROSS STREET Frazier Rd APN 06519010 PARCEL SIZE 1 L, LAND USE APPLICATION# o <br /> OWNER NAME ,Tim Rnggiann PHONE ' <br /> OWNER ADDRESS CRY/STATEMP Linden,CA 95236 <br /> CONTRACTOR Purviance Drillers, INC PHONE209-887-3554 <br /> CONTRACTOR ADDRESS P-0- Box 64 CUYISTATr/ZPLinden CA 95236 <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTORICONSULTANT ADDRESS CRY/STATEIZP <br /> LICENSE R CS7 'C-61 ::D-09 ❑Other NUMBER 377923 ExPIRAnoN DATE 7/31/21 <br /> BILLING PARTY: 1 OWNER ❑CONTRACTOR ❑ SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)0 Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE ❑DomestictPrivate IRigatioNAgricultural ❑Industrial ❑Water Quality Monitoring D Soil Sampting/CharactedUlion <br /> ❑Public Water System <br /> If different from Owner. Water System Name COntact Name ar Phone Number w_ <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Wall Alteration/Modification n Othar (� ''•/(/ N�` <br /> ❑Monitoring Well(s) 9 of wells ❑Soil Boring(s) x or bmhVs L Geotechnical #of ^nes <br /> L3 Out-Of--Service Well ❑Out-UService Well Renewal 11 Cross-Connection Repair 0 V L D <br /> Lr New Pum )(Pump Replacement ❑Pump Repair C Raise Well CasingC Q <br /> WELL CONSTRUCTION ^ ^O <br /> Drilling Method =.:Mud Rotary �Air Rotary ❑Auger' L Cable Tool ❑Push Point a Other `SAN,Jp V ` �O <br /> Proposed Well Depth_ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size_ rA r U�N0UNT <br /> Conductor Casing in diameter I Conductor Casing Depth it N R Y <br /> Well Casing Diameter_In ThkOmess/Gauge/ASTM Schad ❑Steel ❑Plastic ❑Stainless Steel ❑Other D PARTMENT <br /> Grout Seal Depth ft ❑Neat Cement(941b bag/S10 gal water) ❑Sand Cement sack mbf 7 gal water <br /> Bentonite(20%solids) D Other <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> u Concrete Pedestal❑Dimensions:Width it Length it Thick In ❑Christy Box ❑Stove Pipe <br /> PUMP ❑Submersibl Turbine ❑Other HP Pump Set ft Standing Water Level it <br /> I HEREBY CERTIFY THAT 1 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 /> MEEi <br /> '` NOTICEQUIRED FOR!?-SSP . ,T€ON13l!,, <br /> SIGNED TITLE DATE /0- <br /> F <br /> E.!?�)Ty/Z� <br /> —tv---1 — ---.— --s————————— — <br /> IT <br /> Ot <br /> DEPARTMENT U$E�ONLy <br /> Application Accepted By �—��� Date !�/J� Jvy Area ��<� Employee ID# I� <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By CL 1- UWL r wry.� Date v 1 7 WAIVER Received <br /> Soil Boring Inspection By <br /> `\I/N i,�I Date Constructed Well Depth g <br /> COMMENTS_ y C'c+S d p i /j t` <br /> i <br /> PE SC Received Check#/ Amount Permit/ <br /> Codes 117f 17cash Remitted Date Service Re uest# Invoice# Well ID# <br /> - SU ,'A--- $7 <br /> EHD43-M Brttr2079 <br /> WELL IPUAPPERMR <br />