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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 www.S'Oov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOBADDRESS I96SI E Sargent Rd Crn'ZP Lodi,Ca 95240 <br /> CROSS STREET Tully Rd <br /> APN v_ _ l:' J PARCEL SIZE�LAND USE APPLICATION#__1 C <br /> OWNER NAME Tri G <br /> PHONE 209-603-1 308 R <br /> OWNER ADDRESS 9189 N Ashley Lane C"STATEIZIP Stockton,Ca 95212 <br /> CONTRACTOR Purviance Drillers INC <br /> PHONE 2 0 9-8 8 7-3 5 5 4 <br /> CONTRACTOR ADDRESS P-0. Box 64 CnY/STATE1ZlpLinden CA 95236 <br /> SUBCONTRACTORICONSULTANT <br /> PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS <br /> CITY/STATE/ZIP <br /> LICENSE RC-57 C-61 D-09 ❑Other NUMBER 377923 <br /> EXPIRATION DATE 7/31/21 <br /> BILLING PARTY: 71 OWNER =CONTRACTOR ❑SUBCONTRACTORICONSULTANT <br /> DoMEsnc WELL SAMPLING:C General MineraVColiform Bacteria(4391)0 Dibromochioropropane(4392)❑Arsenic(4393) <br /> INTENDED USE ❑DomesfiC/Private Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Character¢a tion <br /> C Public Water System <br /> If difierentfrom Owner. Water System Name <br /> Contact Name or phone Number <br /> TYPE Op WORK New Well G Replacement Well ❑Well Alteration/Modification <br /> ❑Other <br /> C Monitoring Well(s) #of wells ❑Soil Borings) #of borings a or borin <br /> r' Geotechnical ss <br /> Out-Of-Service Well <br /> Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> New Pump X—'Pump Re lacement n Pum Repair r <br /> WELL CONSTRUCTION Raise Well Casing <br /> Drilling Method 7 Mud Rotary --Air Rotary :2 Auger ❑Cable Tool =Push Point ❑ Other <br /> Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel PacklGravel Size <br /> Conductor Casing in diameter ! Conductor Casing Depth ft n dameter <br /> Well Casing Diameter_In Thickness/Gauge/ASTM Sched C Steel D Plastic D Stainless Steel ❑Other <br /> Grout Seal Depth ft ❑Neat Cement(94 lb bag/5-40 gal water) G Sand Cement <br /> G Bentonite(20%solids) ❑Other sack mixfl gal water <br /> Grout Placement Method G Pumped ❑Free FaD Other <br /> • Fail ❑Retardant 1 Accelerator(name) <br /> PEDESTAL Intallecl By C Driller C Pump Contractor ❑ Other <br /> Concrete Pedestal❑Dimensions:Width it Length Thick <br /> in C Christy Box ❑Stove Pipe <br /> PUMP =Submersible Turbine ❑Other HP/?SNp Pump Set D <br /> ft Standing Water Level 15 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 1 AM IN COMPLIANCE WITH ALL <br /> WORKS OMPENS WS. <br /> SIGN <br /> TITLE DATE <br /> i � F FNT <br /> l AFD <br /> --------- <br /> t272020 <br /> /N <br /> MIf,l qFN,�NTY <br /> JJDEPARTMENT USE ONLY RTMENr <br /> Application Accepted By Z'i <br /> Date � .�Jvw y Area � �_/ Employee ID# r L� - <br /> Groutlnspection By Date <br /> 11 SPECIAL Well Permit <br /> Pump Inspection By V-L S( L L, ' Date_W1 r <br /> 1- �.>`l ❑ WAIVER Received <br /> Soil Boring Inspection By Date <br /> COMMENTS Constructed Well Depth ft <br /> PEglnfoB , <br /> Check#/ Amount PermiU <br /> CodesCash Remitted DateInvoice#S� is Re uest# Well ID# <br /> � •' 2'1-Z� <br /> EH043-06 6/1/2019 )/��///•//� // <br /> WELL/PUMP PERMIT <br />