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Y <br /> WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468-3420 <br /> NON-REFUNDABLE PERMIT www'sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> 14602 N N <br /> JOB ADDRESS pine CITY/ZIP Rd Stockton bmD <br /> CROSS STREET APN 0 6 3 0 7 0 2 0 PARCEL StZE LAND USE APPLICATION# A <br /> OWNER NAME Matt Teresi PHONE 209-200-0421 y <br /> OWNER ADDRESS Victor R CITY/STATEaIP Lodi, CA 95240 <br /> CONTRACTOR Purviance Drillers, Inc PHONE 209-887-3554 <br /> CONTRACTOR ADDRESS PO Box 64 CITY/STATE21P Linden, CA 95236 <br /> SUBCONTRACTOR/CONSULTANT n/a PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS n/a CITY/STATE/21P T <br /> LICENSE X C-57 C-61 D-09 Other NUMBER3 7 7 9 2 3 EXPIRATION DATE July ly 3 1 ,� 1 <br /> BILLING PARTY: OWNER CONTRACTOR SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE )Domestic/Private Irrigation/Agricultural _Industrial Water Quality Monitoring _ Soil Sampling/Characterization <br /> Public Water System <br /> If diflerenf if=Owner Water System Name Contact Name m Phone Number <br /> TYPE OF WORK X New Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells Soil Borings) rt of bodngs Geotechnical A of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method AMud Rotary Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depth 300 ft '/w*Excavation 'l in diameter XOpen Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor asing 6 _in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched5� le Plastic Stainless Steel Other <br /> Grout Seal Depth 200(+) ft Neat Cement(94/b bag75-10 gal water) Sand Cement /0-3 sack mixf7 gal water <br /> Bentonite(20%solids) - Other <br /> Grout Placement Method X Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width ft Length It Thick in _Christy Box ._ Stove Pipe <br /> PUMP Submersible Turbine Other HP Pump Set ft Standing Water Level 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 /> MI U�4O R DVANCE NOTICE REQUIRED F INSPE TIONS-PLEASE CALL(209)953- <br /> orp ecretary �r5�/202SIGN - _ TITLE DATE <br /> Few <br /> IV <br /> ED <br /> "A $- <br /> 2020 <br /> oijNry <br /> n -rk <br /> MENT <br /> TMENT SE ONLY <br /> Application Accepted B Date Z-57-j Area Employee ID# <br /> Grout Inspection By \. Date Z W6 PECIAL Well Permit <br /> Pump Inspection Byd�rt 1�; r_� Date L 'v WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth It <br /> COMMENTS <br /> PE SC Received heck#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By RemittedI Service Request# <br /> 2 <br /> '0 <br /> EHD43-06 6/112019 WELL/PUMP PERMfr <br />