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SAN JOADUIN COUNTY ENVIRONMENTAL HEALTH DEPARTWELUPUMP PERMIT <br /> MENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)4683420 <br /> NON-REFUNDABLE PERMIT VVWW.S Ov.or /ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOBADDRESS 1763 S. Hewitt Rd CITy/zlP Linden 95236 Ln <br /> M <br /> CROSS STREET C'c1p rcTncll i S Rd APN 18330007 PARCEL SIZED <br /> LAID USE APPLICATION# 0 <br /> OWNER NAME BWC Weststeyn, LP m <br /> PHONE y <br /> OWNERADDRESS 1763 S. Hewitt Rd CITYISTATE21P_Linden,CA 95236 <br /> CONTRACTOR Purviance Drillers INC PHONE209-887-3554 <br /> CONTRACTOR ADDRESS P•0• BOX 64 CrTY/STATE/ZIPLinden CA 95236 <br /> SUBCONTRACTOR/CONSULTANT <br /> PHONE <br /> SUBCONTRACTORICONSULTANT ADDRESS Crry/STATE/ZIP <br /> LICENSE X C-57 _ C-61 ❑D-09 ❑Other NUMBER 377923 EXPIRATION DATE 7/3 1/2 1 <br /> BILLING PARTY; -OWNER 'i CONTRACTOR -i SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:C General Mineral/Coliform Bacteria(4391)i I Dibromochloropropane(4392)C Arsenic(4393) Y/I� <br /> INTENDED USE omeStic/Private ❑Irrigation/Agricultural 5 Industrial ;;Water Quality Monitoring Soil Sampling/Characterization �• l 1 y T <br /> Public Water System <br /> If different from Owner Water System Name I/ D <br /> Contact Name a Prlone Number <br /> TYPE OF WORK C New Well G Replacement Well D Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells Ll Soil Boring(s) #ofbwngs cid ?0?0 <br /> Out-Of-Se vice Well Geotechnical ��N <br /> Out-Of-Service Well Rene I 2 CrOSS-Connection Repair NEIN RQQ / CO <br /> New Pum 2 Pum Replacement um Repair Raise Well Casin <br /> WELL CONSTRUCTION l N �TA ANT y <br /> Drilling Method .Mud Rotary :Air Rotary _I Auger r;Cable Tool Push Point Other TIS <br /> Proposed Well Depth It Excavation in diameter 7 Open Bottom ❑Gravel Pack/Gravel Size FNT <br /> Conductor Casing in diameter / Conductor Casing Depth ft in diameter <br /> Well Casing Diameter;in Thickness/Gauge/ASTM Sched <br /> Steel 7 Plastic fi Stainless Steel ;]Other <br /> Grout Seal Depth -ft �Neat Cement(94/b bagl5 10 gat water) Sand Cement <br /> Bentonite(20%solids) D Other sack mixl7 gal water <br /> Grout Placement Method c Pumped rl Free Fall L'Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By -Driller _Pump Contractor C Other <br /> Concrete Pedestal CDlmensions:Width ft Length ft Thick <br /> in Z Christy Box D Stove Pipe <br /> Submersibl Turbine C Other PUMP C Hp <br /> Pump Set ft Standing Water Level ft <br /> I 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 I WITH ALL <br /> WORKERS COMPENSATION LAWS. AM IN COMPLIANCE WIf <br /> )UR ADVANCI_NC3i;CE?Rrf.'11lIREr,:FL1^/Jrptgp C3-t2r4R <br /> SIGNED <br /> T ,_ / <br /> ITLE `-"'_Y "—7 DATE o'S <br /> ------------------- <br /> ------------------- <br /> O <br /> • <br /> i <br /> 7� DEPARTMENT USE ONLY <br /> Application Accepted By Iw Z_Z__ Date /J 6 rad�ui0 y C;G <br /> Area Employee ID# / 1 <br /> Grout Inspection By Date 7 SPECIAL Well Permit <br /> Pump Inspection By i- �•tiL Date <br /> Soil <br /> -.111L�j,'hC , WAIVER Received <br /> Soil Boring Inspection By <br /> COMMENTS Date Constructed Well Depth ft <br /> PE SC Received Check#/ Amount <br /> Codes Info Cash Remitted Date PermiV So Service Re uest Invoice# ��Well ID# <br /> 3 � �� <br /> 1 <br /> EHD 43-06 8/11/2079 "Y <br /> S /J WELL!PUMP PERMIT <br />