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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 L www.S ov.or /ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS �67 ;E E, St le'lij) ��li-V CrrY/LPLockeford,CA 95237 r—" <br /> M <br /> CROSS STREET St Rt Hwy 8Q APN a;(,j S Q o <br /> PARCEL SIZE ) LAND USE APPLICATION# p <br /> OWNER NAME G.Qrard Warmardam PHONp209 334 4904 y <br /> OWNERADDRESS y <br /> CITY/STATE/ZIP �---r�2'A <br /> CONTRACTOR Purviance Drillers, INC PHONE209-887-3554 <br /> CONTRACTOR ADDRESS P-0- Box 64 CITY/3TATE/ZIPLi nden CA 95236 <br /> SUBCONTRACTORICONSULTANT PHONE <br /> SUBCONTRACTORICONSULTANT ADDRESS CITY/STATEIZIP <br /> LICENSE k C-57 C-61 D D-09 ❑Other NUMBER 377923 EXPIRATION DATE 7/31/21 <br /> BILLING PARTY: 'OWNER D CONTRACTOR '-1 SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING:G General Mineral/Coliform Bacteria(4391)U Dibromochloropropane(4392)L Arsenic(4393) <br /> INTENDED USE U DomestictPrivate Irrigation/Agricultural Ci Industrial C Water Quality Monitoring r,,Soil Sampling/Characterization <br /> D Public Water System ^4 <br /> Mdifferent from Owner. Water System Name Contact Name or Phone Number /" Y,y/ <br /> TYPE OF WORK ❑New Well C Replacement Well i;Well AlterationlModfigtion i.i Other EC '�I/ <br /> D Monitoring Well(s) #Of wells '-Soil Borin s :of wnnps *of Bonn s �D <br /> 9O Geotechnical e <br /> Out-Of-Service Well U Out-Of-Service Well Renewal G Cross-Connection Repair T <br /> New Pum PC <br /> um Replacement G Pum Repair Raise Well Casing l• <br /> WELL C ,Jn <br /> CONSTRUCTION Q 7020 <br /> Drilling Method Mud Rotary U Air Rotary J Auger' G Cable Tool C Push Point Other N Q(,j(7� <br /> Proposed Well Depth ft Excavation in diameter D Open Bottom D Gravel Pack/Gravel Size in RONMENT�NTy <br /> Conductor Casing in diameter / Conductor Casing Depth ft DEPAR7 <br /> Well Casing Diameter_in Thlckness/Gauge/ASTM Sched - Steel ❑Plastic U Stainless Steel ❑Other ENT <br /> Grout Seal Depth ft Neat Cement(94 lb bag/5-10 gal water) D Sand Cement sack mW7 gal water <br /> D Bentonite(20%solids) 7 Other <br /> Grout Placement Method Pumped 7 Free Fall U Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By _Driller .,Pump Contractor C Other <br /> :i Concrete Pedestal IiDimenslons:Width ft Length It Thick in C;Christy Box ❑Stove Pipe <br /> PUMP Submers ble(!Turbine D Other HP jo tanding Water Level l _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 IAM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> 'U%,t:VANCE NOTICE REQUiREn i=:;- .-:. n_,_::�rrS-r,.I~nSi=C."M-t-r�.nc*��, � ;•, <br /> SIGNED Y - G� 1% 0/ <br /> TITLE DATE 1Q/ ZI/r, <br /> � 8 <br /> ------------------------------------------- <br /> 1 DEPARTMENT USE ONLY 1J 1 <br /> Application Accepted By ��_ /C— Date ✓ /�; J^(� Area / ` Employee ID# <br /> Grout Inspection By Date r_7 SPECIAL Well Permit <br /> Pump Inspection By i�,.� aLG � � Date T2,11,J4 7 WAIVER Received <br /> Soil Boring Inspection By Date cnncfnreted Well Depth <br /> COMMENTS �o,!. < jr!C� `>i — �/ tt tI= t <br /> PE SC Received Check#! Amount Permit/ <br /> Codes Info BV gash Remitted pate Service Re uest# Invoice# Well ID# <br /> EHO43-08 6f11r1o19 <br /> �I,�, 11,S76 <br /> /S 76 ): r� WELL/PUMP PERMIT <br />