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WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)4663420 <br /> NON-REFUNDABLE PERMIT www.sjqov.orq/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOBADDRESS 1763 S. Hewitt Rd CITy21P Linden,CA 95236 m <br /> CROSS STREET Capp-rnpn l i s Rd APN 18330007 PARCEL SIZE LAND USE APPLICATION# c <br /> 0 <br /> OWNER NAME BWC Weststeyn LP PHONE N <br /> OWNER ADDRESS 1 7F,-1 4 HP4rj t't' Rd CITYISTATEIZIP Llnderi,CA 95236 <br /> CONTRACTOR Purviance Drillers, INC PHONE209-887-3554 <br /> CONTRACTOR ADDRESS P.O. Box 64 CITYISTATEIZIPLinden CA 95236 <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITYISTATE/ZIP <br /> LICENSE R C-57 _C-61 ❑D-09 Other NUMBER 377923 EXPIRATION DATE 7/3 1/2 1 <br /> BILLING PARTY: :-.OWNER E:CONTRACTOR G SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING:C General MineraUColiform Bacteria(4391)i_Dibromochloropropane(4392)C Arsenic(4393) /1d <br /> INTENDED USE omestic/Private ❑Irrigation/Agricultural 7 Industrial L Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System C �� <br /> If different from Omer. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK 0 New Well C Replacement Well L Well Alteration/Modification Other OC <br /> D Monitoring Well(s) #of wells ❑Soil Boring(s) #of bmngs ❑Geotechnical #of borings T 0, <br /> C Out-Of-Service Well C Out-Of-Service Well Renewal Cross-Connection Repair Sq2020 <br /> D New Pum Pum Replacement Pum Repair Raise Well CasingNQq Q(J( <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary i;Air Rotary ❑Auger C Cable Tool Push Point 11 Other Eq N p&pMENOq LNT Y <br /> Proposed Well Depth ft Excavation in diameter C Open Bottom n Gravel Pack/Gravel Size in diameter ARTMEh/] <br /> Conductor Casing In diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_In Thickness/Gauge/ASTM Sched Steel C Plastic tl Stainless Steel .,Other <br /> Grout Seal Depth ft C Neat Cement(94 Ib bag/b-10 gal water) f_7 Sand Cement sack mixl7 gal water <br /> Bentonite(20%solids) :1 Other <br /> Grout Placement Method G Pumped ❑Free Fall Ll Other C Retardant/Accelerator(name) <br /> PEDESTAL Installed By _Driller Pump Contractor C Other <br /> L Concrete Pedestal CDimensions:Width It Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP C Submersible'V,Turbine ❑Other HP Pump Set ft Standing Water Level ft <br /> 1 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 IAM IN REQUIRED CEN ALL <br /> WORKERS COMPENSATION LAWS. <br /> I ' <br /> 1�-,'AP-ICE NOTI7C�:REQUIRE-: FCt 7th.-:.: r77 <br /> SIGNED / I1 TITLE .. DATE71, <br /> V <br /> ------------------------- <br /> I <br /> D-EPARTMENT US NLY te/ <br /> Application Accepted By jry `� Date r <br /> Q;U grea y�R Employee ID# FPC <br /> Grout Inspection By Date 7 SPECIAL Well Permit <br /> Pump Inspection By '-a ( ;, Date_J\J1-j V G� -1 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Check#/ Amount Permitl <br /> Codes Info B ash Remitted Date Service Re uest# �Involce Well ID# <br /> OSb d- *?7 <br /> v i <br /> EHD 43-pfi 8/1712019 <br /> WELL/PUMP PERMIT <br />