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WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 186$EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468-3420 <br /> NON-REFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> Jos ADDRESS 1OR99 E. Woodbridge CrrlZlPLodi,CA 95220 m <br /> D <br /> CROSS STREET R n r k R(l APN(11 7 2 4 fl 1 4 PARCEL SIZE LAND USE APPLICATION# o <br /> M <br /> m <br /> OWNER NAME I(d rr1e Gini PHONE m <br /> OWNERADDRESS P.O- Box 644 CITY/sTATEIZIPVictor,CA 95253 <br /> CONTRACTOR Purviance Drillers, INC pHONE209-887-3554 <br /> CONTRACTOR ADDRESS P-O. Box 64 CITYISTATE/ZIPLlnden CA 95236 <br /> SUBCONTRACTORICONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE21P <br /> LICENSE k C-57 �C-61 D-09 i i Other NUMBER 377923 EXPIRATION DATE <br /> BILLING PARTY: ;:OWNER ❑CONTRACTOR 1.1 SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:G General Mineral/Coliform Bacteria(4391)11 Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE L'Domestic/Private XIrrigationlAgricultural a Industrial !-,Water Quality Monitoring ❑Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well ❑Replacement Well Well Alteration/Modification it Other <br /> Monitoring Well(s) #ofweils [;Soil Borings) #ofborings ;Geotechnical #of borings <br /> 7 Out-Of-Service Well ❑Out-Of-Service Well Renewal G Cross-Connection Repair <br /> New Pum ❑Pump Replacement XPu!,np Repair C Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary 7 Air Rotary ❑Auger 'Cable Tool ';Push Point ❑ Other <br /> Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> G Conductor Casing In dlameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad Steel ❑Plastic ti Stainless Steel D Other <br /> Grout Seal Depth ft D Neat Cement(94 lb bag/5-10 gal water) 2 Sand Cement sack mixF7 gal water <br /> L Bentonite(20%solids) ❑Other <br /> Grout Placement Method 'i Pumped -1 Free Fall C Other I'Retardant/Accelerator(name) <br /> PEDESTAL Installed By 'Driller Pump Contractor C Other <br /> Concrete Pedestal❑Dimensions:Width ft Length It Thick in G Christy Box C Stove Pipe <br /> PUMP ❑Submersible).(Turbine 'Other HP Pump Set ft Standing Water Level ft <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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATI N LA <br /> ;? ,:i vt-.�'�r-,iii i�l ll..1,[i?C ..il sf�::.-'.::: (�R ON C,�".E t� /f'�.�r1JC CALL"209)&'53 ✓C;' <br /> SIGNEDl�p TITLE �--CM1 o DATE/` 3 C/\� <br /> IMENT <br /> EIVE® <br /> Er <br /> `x 10 2020 <br /> UlN COUNTY <br /> ONMENTAL <br /> EPARTMENT <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Area Employee ID# / <br /> Grout Inspection By Date U SPECIAL Well Permit <br /> Pump Inspection By t,.-L.".Sk2 (^,X ,, IL-L Date 7 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date PermiU <br /> Codes Info B Invoice# Well ID# <br /> Cash Remitted S ce Re oast# <br /> �13K;t 7 7 0() <br /> -7 17fo <br /> EHD4346 6/11/2019 <br /> WELL!PUMP PERMIT <br />