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WELL/PUMP PERMIT <br /> SAN JOACUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468-3420 <br /> NON-REFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES'I YEAR FROM DATE ISSUED <br /> Jos ADDRESS 7986 Beecher Rrl CITYMP Str)rkt-nQ rA 952115 <br /> m <br /> CROSS STREET Comstock RD APN 089119n-41 D <br /> PARCEL SIZE LAND USE APPLICATION# S <br /> {Jat'> l �1 PHONE m <br /> OWNERNAME PC, ,�(�I /1 ��� m <br /> �11—`tt-351 A.�V6S- tin <br /> OWNER ADDRESS 7986 Bee(-hpr Rd Cm'/STATE/ZIP gtpn CA 9521 5 <br /> )G toll-� <br /> CONTRACTOR Purviance Drillers, INC PHONE 2 0 9—8 8 7—3 5 5 4 <br /> CONTRACTOR ADDRESS P-0- BOX 64 Crry/STATEMPLinden CA 95236 <br /> SUBCONTRACTORICONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP <br /> LICENSE X C-57 _C-61 _D-09 Other NUMBER 377923 EXPIRATION DATE 7/31/21 <br /> BILLING PARTY: OWNER ❑CONTRACTOR C SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:L General Mineral/Coliform Bacteria(4391)a Dibromochloropropane(4392)G Arsenic(4393) <br /> INTENDED USEDomestic[Prtvate D Irrigation/Agricultural is Industrial C Water Quality Monitoring C Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System Name Contact Name or Pitone Number <br /> TYPE OF WORK New Well L Replacement Well C Well Alteration/Modification C Other <br /> Monitoring Well(s) #of wells C Soil Boring(s) #of borings Geotechnical #of borings <br /> _I Out-0f-Service Weil ❑Out-Of-Service Well Renewal a Cross-Connection Repair <br /> New Pump D Pump Replacement IAum2 Repair D Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method G Mud Rotary D Air Rotary Auger D Cable Tool ,Push Point 1 Other <br /> Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad a Steel D Plastic D Stainless Steel F)Other <br /> Grout Seat Depth ft _:Neat Cement(94 lb bag/5-10 gal water) t7 Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) Lj Other <br /> Grout Placement Method Pumped :.: Free Fall 11 Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By -Driller _Pump Contractor C Other <br /> C Concrete Pedestal ]Dimensions:Width It Length ft Thick in 1 Christy Box D Stove Pipe <br /> PUMP Submersible"Turbine G Other HP Pump Set ?I 9 ft Standing Water Level ft <br /> I 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 CO ENS A LAWS. <br /> SIGNED TITLEv©wVLt 1'- DATE 1 <br /> I <br /> � I I <br /> I I <br /> I I I <br /> i <br /> aLo ) 20I <br /> i <br /> L <br /> o 1 COUNTY <br /> ENTAL <br /> RTMENT <br /> LL <br /> I i <br /> DEPARTMENT US� NLY <br /> Application Accepted By Date Area � � Employee ID# t ' <br /> Grout Inspection By Date IJ SPECIAL Well Permit <br /> Pump Inspection By `i owl,S Li. ty f/l� Date \L1 1 11 v Ll WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#! Amount Permit/ <br /> Codes Info pate Cash Remitted Service Request# Invoice# Well ID# <br /> L 1 <br /> ch <br /> EHD4343 an112019 <br /> WELL/PUMP PERMIT <br />