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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 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 /> JOB ADDRESS 2R1g2 R Rive= Rd, Crry/LP Escalr)n,C'A 95320 m <br /> D <br /> CROSS STREET Burwood Ln APN 24722004 PARCEL SIZE-'J LAND USE APPLICATION# O <br /> A <br /> OWNERNAME Richard Lial PHONE n <br /> OWNERADDRESS 19624 S. Van Allen Rd CIY/STATE/7JP_ESCaIOn.,C'A 99320 <br /> CONTRACTOR Purviance Drillers, INC PHONE209-887-3554 <br /> CONTRACTOR ADDRESS P-Q. BOX 64 CITYISTATE/LPL i nde n CA 95236 <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTORICONSULTANT ADDRESS CITY/STATEILP <br /> LICENSE K C-57 _C-61 - D-09 C Other NUMBER 377923 EXPIRATION DATE 7/31/21 <br /> BILLING PARTY: E OWNER _CONTRACTOR I.i SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING:C General Mineral/Coliform Bacteria(4391)11 Dibromochieropropane(4392)C Arsenic(4393) <br /> INTENDED USE ❑Domestic/Private ?. Vrrigation/Agricultural ;.;Industrial Water Quality Monitoring C Soil Sampling/Characterization <br /> Public Water System <br /> it different from Owner. Water System Name contact Name or Phone Number <br /> TYPE OF WORK C New Well C Replacement Well C Well Alteration/Modification J Other <br /> C Monitoring Well(s) #of wells l Soil Borings) #of borings r;Geotechnical #of borings <br /> Out-Of-Service Well ❑Out-Of-Service Well Renewal .-I Cross-Connection Repair <br /> New Pump Pump Replacement qp Repair C Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ; Mud Rotary Air Rotary -Auger C Cable Tool Push Point Other <br /> Proposed Well Depth ft Excavation in diameter i I 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 Sched [7 Steel i i Plastic -I Stainless Steel :1Other <br /> Grout Seal Depth ft -- Neat Cement(94 lb bag/5-10 gat water Sand Cement sack mix17 gal water <br /> Bentonite(20%solids) •C Other <br /> Grout Placement Method Pumped _-:Free Fall ❑Other C Retardant/Accelerator(name) <br /> PEDESTAL Installed By =Driller C Pump Contractor Other <br /> -Concrete Pedestal LDimensions:Width ft Length It Thick in L Christy Box C Stove Pipe <br /> PUMP �2 Submersible Turbine G Other HP Pump Set ( It Standing Water Level�o ft <br /> 1 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 LAW <br /> rE;I!�1RED FC:/;y�Pd�SP/t"ted i tot 3-.LEASE CALL(209)953J697 <br /> SIGNED TrrtE l ifyVliT6�C, � DATE 12 —13 <br /> ENT <br /> VED <br /> 44 2020 <br /> COUNTY <br /> ENTAL <br /> ARTMENT <br /> / DEPARTMENT USE ONLY (' <br /> Application Accepted By —Z—�_ Date ' ? '- Area Employee ID# f <br /> Grout Inspection By Date LJ SPECIAL Well Permit <br /> Pump Inspection By :+,yak L F Date 1 ✓ n WAIVER Received / <br /> Soil Boring Inspection By Date Constructed Well Depth R �O <br /> COMMENTS / <br /> PE Sc Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cash Remitted Service Re uest# <br /> 3 .? ��-J '7 i2- 1.0 0 t G� <br /> EH0 43-06 6/11/4019 <br /> WELL/PUMP PERMIT <br />