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, ter <br /> WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205.6232(209)468-3420 <br /> NON-REFUNDABLE PERMIT www.sjqov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 1 S1 6 W. Ar_msf mnc� Rd CITvl21P_ Lodi 95242 m <br /> a <br /> CROSS STREET_Davis Rd APN 0 5 5 2 2 OA rf PARCEL SIZE LAND USE APPLICATION# p <br /> A <br /> OWNERNAME Arlene T,ow;4r)z PHONE m <br /> OWNERADDRESS 1 515 W. Armstrong Rd Crry/STATE1zIP Lodi,CA 95242 <br /> CONTRACTOR Purviance Drillers, INC PHONE209-887-3554 <br /> CONTRACTOR ADDRESS P-O. Box 64 CnYISTATE21PL i nden CA 95236 <br /> SUBCONTRACTORICONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATEIZIP <br /> LICENSE 2 C-57 ❑C-61 ❑D-09 C Other NUMBER 377923 EXPIRATION DATE 7/31/21 <br /> BILLING PARTY: ❑OWNER G CONTRACTOR G SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:G General Mineral/Coliform Bacteria(4391)L1 Dihromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USEOmestic/Private D Imgation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> Public Water System <br /> IfdiNerent from Owner: Water System Name Contac[Name or Phone Number <br /> TYPE OF WORK D New Well D Replacement Well P.Well Alteration/Modification ❑Other <br /> ❑Monitoring Well(s) #of wells ❑Soil Boring(s) #ofborings ❑Geotechnical #of borings <br /> D Out-Of--Service Well C Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pump Pump Replacement 3 Pump Repair ❑Raise Well Casio <br /> WELL CONSTRUCTION <br /> Drilling Method .i Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point D Other <br /> Proposed Well Depth ft Excavation_ in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> 0 Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched n Steel ❑Plastic D Stainless Steel ❑Other <br /> Grout Seal Depth ft ❑Neat Cement(94 lb bag/5-id gal water) Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) ❑Other <br /> Grout Placement Method 11 Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller n Pump Contractor ❑ Other <br /> u Concrete Pedestal❑Dimensions:Width ft Length R Thick in J Christy Box ❑Stove Pipe <br /> PUMP Submersible❑Turbine ❑Other HP Pump Set ft Standing Water Level L-105 _it <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 /> I� R ADVANCE NOTICE REQUIRED FO INSPECTIONS-PLEASE CALF.(209)953-7697 <br /> SIGNED ypt-z > TITLE DATE (&I�w <br /> $ 11 T-T- F— <br /> all <br /> fl <br /> --------------- <br /> D d <br /> ll X-Z 1' <br /> t U V" 10 2020 <br /> b a' JOAQUl,1)C <br /> E V/RONENT�N <br /> � Ty DEPgRTMEh,._ <br /> DEPARTMENT USE ONLY (� f7 <br /> Application Accepted By r—� Date liO �{t>r1 D Area 1 01 C Employee ID# r K <br /> Grout Inspection By Date_ ❑ SPECIAL Well Permit <br /> Pump Inspection By_ h'kC_S_ fu Data R 70't C ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permit/ <br /> Codes Info B Cash Remitted Se Ice Re ue t# Invoice# Well ID# <br /> 55J <br /> 7 <br /> EHO 43-06 6/11/2019 <br /> WELL/PUMP PERMIT <br />