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WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468-3420 <br /> NON-REFUNDABLE PERMIT www.sigov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOBADDRESS 6161 Cherokee Rrl CrTYlZIP Stocktori,CA 95215 m <br /> a <br /> CROSS STREET T.gip r i n R d APN 0 8 7 2 5 0 0 4 PARCEL SIZE d ✓ LAND USE APPLICATION# o <br /> A <br /> OWNER NAME Davi r3 ('P111m <br /> PHONE ur <br /> OWNERADDRESs 6161 Cherokee Rd CITYISTATEMP Gtnr•kYon, .a 9521 S <br /> CONTRACTOR Purviance Drillers, INC PHONE2O9-887-3554 <br /> CONTRACTOR ADDRESS P-O- BOX 64 CITY/STATEI7JPL i nden CA 95236 <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP <br /> LICENSE R C-57 11 C-61 =:D-09 Other NUMBER 377923 EXPIRATION DATE 7/3 1/2 1 <br /> BILLING PARTY: D OWNER ;i CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:G General MineraUColiform Bacteria(4391)_]Dibromochloropropane(4392)G Arsenic(4393) <br /> INTENDED USE omesticlPrivate Irrigation/Agricultural _;Industrial Water Quality Monitoring C Soil Sampling/Characterization <br /> D Public Water System <br /> If different from Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well C Replacement Well ;.;Well Alteration/Modification ❑Other <br /> Monitoring Well(s) #of wells D Soil Boring(s) #of borings ❑Geotechnical #of borings <br /> Out-Of-Service Well ❑Out-Of-Service Well Renewal C Cross-Connection Repair <br /> New Pum Pump Replacement %Pump Repair C Raise Well Casino <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary J Air Rotary Auger L:Cable Tool �;Push Point Other <br /> Proposed Well Depth ft Excavation in diameter 'I Open Bottom U Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched ^Steel i l Plastic ;Stainless Steel D Other <br /> Grout Seal Depth ft Neat Cement(94 lb bag/5-10 gal water) f:Sand Cement sack mix/7 gal water <br /> L Bentonite(20%solids) L;Other <br /> Grout Placement Method 7,Pumped Ci Free Fall ❑Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By -Driller L Pump Contractor Other <br /> Concrete Pedestal[!Dimensions:Width ft Length ft Thick in Christy Box E Stove Pipe <br /> PUMP <br /> %Submersible-Turbine :;Other HP Pump Set I LA-1 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�) 7WTHE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATIWS.is4it3¢%c Ellfii r if"r'Ji ltdS 3- iAF r,F'Ct�LL(2t)aEL7SIGNED TITLE UW UL-Q-�y DATE 2 C <br /> L <br /> ty <br /> IWF <br /> MENT <br /> i EIVED <br /> 1 4 2020 <br /> UIN COUNTY <br /> NMENTAL <br /> DEPARTMENTUSE ONLY <br /> EPARTMENT <br /> Application Accepted 8y �LLr-- Date �� ��% �Jr J Area �7 Employee ID# I I <br /> Grout Inspection By Date U SPECIAL Well Permit <br /> Pump Inspection By Vt L A t UlfLi�- (ty - Date ` 1��o ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#! Amount Permit! <br /> Codes Info B Cash Remitted Date ervice Re uest# Invoice# Well IDA <br /> 7 3 <br /> EH043-06 6/112019 <br /> WELL!PUMP PERMIT <br />