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WELLIPUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1$66 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468-3420 NON-REFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED m JOB ADDRESS 21880 Eastern Heights Rd CITY/Zip L,indPn C'A 9523E m CROSS STREET Fine Rd APN 09303013 PARCEL SIZE LAND USE APPLICATION# o A m OWNER NAME Joe I('a Yr1 n PHONE in OWNER ADDRESS 21880 Pa Stprn HpigbtS Rd CITYISTATEIZIP Linden, .A 95236 CONVMCOR Purviance Drillers, INC PHONE209-887-3554 CONTRACTOR ADDRESS P-O- BOX 64 CITYISTATE/ZIPLinden CA 95236 SUBCONTRACTORICONSULTANT PHONE SUBCONTRACTORICONSULTANT ADDRESS CITY/STATE21P LICENSE X C-57 C-61 ❑D-09 C Other NUMBER 377923 EXPIRATIoN DATE 7/31/21 BILLING PARTY: ❑OWNER ❑CONTRACTOR ❑ SUBCONTRACTORICONSULTANT DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)l7 Dibromochloropropane(4392)0 Arsenic(4393) INTENDED USE Domestic/Private U Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring 0 Soil Sampling/Characterization 0 Public Water System if different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK G New Well f]Replacement Well ❑Well Alteration/Modification C Other Monitoring Well(s) #of wells O Soil Borings) #of borings ❑Geotechnical #of borings Out-Of-Serv(ce Well 0 Out-Of-Service Well Renewal G Cross-Connection Repair C New Pum !Pump Replacement U Pump Repair ❑Raise Well Casing WELL CONSTRUCTION Drilling Method 0 Mud Rotary Ll Air Rotary D Auger 0 Cable Tool L'Push Point ❑ Other Proposed Well Depthft Excavation in diameter n Open Bottom C Gravel Pack/Gravel Size in diameter 0 Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter_in Thickness/Gauge/ASTM Schad n Steel U Plastic C Stainless Steel LI Other Grout Seal Depth ft ❑Neat Cement(94 lb bag/5-10 gal water) a Sand Cement sack mixr7 gal water ❑Bentonite(20%solids) ❑Other Grout Placement Method E.Pumped C Free Fall ❑Other C Retardant/Accelerator(name) PEDESTAL Installed By C Driller C Pump Contractor E Other C Concrete Pedestal GDimensions:Width ft Length ft Thick in 0 Christy Box 0 Stove Pipe PUMP Submersible Turbine ❑Other HP Pump Set ft Standing Water Level (`It 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. n't'm ^UR ADVANCE NOTICE REQUIPLEASE FOR INSPE TIO 5-. LEASE CALF.(209)95 719/ SIGNED e 1 tf�c� ilk TIME DATE A- AYMENT CEIVED vriV 10 2020 AQUIN COUNTY ENVIRONMENTAL DEPARTMENT U E ONLY HEAlTHDEPARTMENT Application Accepted By Date /I d Area CiC- Employee ID#_ F Grout Inspection By Date J SPECIAL Well Permit Pump Inspection By 1Ai'01 G, Ck [► pq &nL Date u.\L�'1I j;q C ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS PE SC Received Check#/ Amount Date Permit( Invoice# Well ID# Codes Info Cash Remitted Se t e Request# 3F JSd o- 477 EHD43-06 6111/2019 WELL/PUMP PERMIT