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WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205•6232(209)4683420 <br /> NON-REFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS E. Handrw 1 R D y <br /> $408 CITY/ZtP__Lodh 9S7dO m <br /> CROSS STREET A l p i n e g(3 APN _06306026 PARCEL SIZE`✓1ND USE APPLICATION# O <br /> a <br /> OWNERNAME Westwind Farms PHONE M <br /> OWNERADDRESS Z4()C) E- Handpl Rri Cmr/STATEMP T,nr1i r['A Q5240 <br /> CONTRACTOR Purviance Drillers, INC PHONE 2 0 9-8 8 7-3 5 5 4 <br /> CONTRACTOR ADDRESS P-O- BOX 64 CITY/STATE21PLinden CA 95236 <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTORICONSULTANT ADDRESS CITY/STATE/Zip <br /> LICENSE R C-57 El C-61 C D•09 ❑Other NUMBER 377923 ExPIRATION DATE 7/31/21 <br /> BILLING PARTY: D OWNER U CONTRACTOR G SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING:0 General Mineral/Coliform Bacteria(4391)0 Dibromochloropropane(4392)0 Arsenic(4393) <br /> INTENDED USEomestic/Private 0 Irrigation/Agricultural G Industrial ❑Water Quality Monitoring 0 Soil Sampling/Characterization <br /> nC Pubfic Water System <br /> If different from Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ;New Well G Replacement Well [i Well Alteration/Modification L Other <br /> U Monitoring Well(s) #of wells D Soil8oring(s) #ofborings G Geotechnical #of borings <br /> Out-Of-Sere ce Well D Out-Of-Service Well Renewal U Cross-Connection Repair <br /> C New Pump JV Pump Replacement '0 Pump Repair 0 Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method -Mud Rotary C Air Rotary G Auger 0 Cable Tool D Push Point 0 Other <br /> Proposed Well Depth ft Excavation in diameter tl Open Bottom 0 Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched G Steel C plastic D Stainless Steel 0 Other <br /> Grout Seal Depth ft 0 Neat Cement(94 lb bag/5-10 gal water) 0 Sand Cement sack mix/7 gal water <br /> U Bentonite(20%solids) D Other <br /> Grout Placement Method I I Pumped G Free Fall D Other D Retardant/Accelerator(name) <br /> PEDESTAL Installed By G Driller C Pump Contractor U. Other <br /> Concrete Pedestal LDimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP VSubMersibleD Turbine D Other HP Pump Set ft Standing Water Level k e <br /> 1 HEREBY CER IFY 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 /> :> >�,ADVANCE NOTICE FtE•...I.IR..D FOR . sP... 1.,N5 LE,-SE GALL(20R)._.2-7!397 <br /> , <br /> SIGNED i "/.CG TITLE DATE lOD <br /> 0 <br /> U,iTqp, <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date / ���' Area C C Employee ID#� <br /> Grout Inspection By Date I Ll SPECIAL Well Permit <br /> Pump Inspection By��IDL,S to ( c, + Date ��(I li '9OI jZ WAIVER Received <br /> Soil Boring Inspection By Dale Constructed Well Depth It <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permit] <br /> Codes Info ZOE <br /> Remitted ervi e e uest# Invoice# Well 11393 OHO 7 <br /> EHO 43-06 6/1112019 <br /> W ELL!PUMP PERMIT <br />