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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.S Ov.Of /ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOBADDRESS 14642 E. Eight Mile Rd crrrl2jp Linden 95236 <br /> CROSS STREET Jack Tone Rd APN 09102009 PARCEL SIZE m <br /> '_LAND USE APPLICATION# p <br /> OWNERNAME Janet Nicollnl M <br /> PHONE <br /> OWNERADDRESS _425 Valencia Dr CITY/STATElZIFSan Francisco,CA 94080 <br /> CONTRACTOR Purviance Drillers, INC PHONE209-887-3554 <br /> CONTRACTOR ADDRESS P-0- BOX 64 CITYISTATE21PLinden CA 95236 <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> �SUBCONTRACTOR/CONSULTANT ADDRESS CITWSTATEMP <br /> LICENSE X C-57 .,C-61 �D-09 L Other NUMBER 377923 EXPIRATION DATE 7/31/21 <br /> BILLING PARTY: .-i OWNER L CONTRACTOR LI SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING:G General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE DOmestic/Private C Irrigation/Agricultural E Industrial F Water Quality Monitoring C Soil Sampling/Characterization <br /> Public Water System A <br /> If different from Owner. Water System Name Contact Name or Phone Number <br /> TYPE Or WORK New Well E Replacement Well 'I Well Alteration/Modification E Other C C, <br /> ^_Monitoring Well(s) #of wells D Soil Boring(s) #of borings aof to s <br /> Geotechnical n9 <br /> Out-Of-Service Well 7 Out-Of-Service Well Renewal D Cross-Connection Repair 73 O11 <br /> New Pump Pump Re lacementPump Repair C Raise Well Casi 4 202 <br /> 0 <br /> WELL CONSTRUCTION X7 <br /> Drilling Method _Mud Rotary :Air Rotary G Auger Cable Tool 1.Push Point C Other 4 ) <br /> Proposed Well Depth ft Excavation in diameter J Open Bottom CI Gravel Pack/Gravel Size I 0NMENDUNTy <br /> Conductor Casing in diameter I Conductor Casing Depth ft EPq R7TA L <br /> Well Casing Diameter—in Thickness/Gauge/ASTM Sched C Steel C Plastic G Stainless Steel t l Other ENT <br /> Grout Seal Depth ft ,;Neat Cement(94 Ib bag/5.10 gal water) L Sand Cement sack mixr7 gal water <br /> C Bentonita(20%solids) 0 Other <br /> Grout Placement Method Pumped ❑Free Fall C Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller E Pump Contractor L Other <br /> Concrete PedestalLiDimensions:Width ft Length ft T 'Ck in ❑Christy Box G StovePlpe <br /> PUMP Submersible Turbine :;Other HP Pump Set ft Standing Water Level It <br /> I HEREBY CER IFY THAT t 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 LAWS. <br /> /rte ;`j i\GE NrsTlt� ?r!9ttt- -.,•r,trf�� 1-1.1 . - <br /> SIGNED Qa.t-QS'�YCV�JI,�,Luti-ct.CJ TITLE a .. /13 -' <br /> DATE G� <br /> t <br /> 1 <br /> 5 , <br /> -------------------- <br /> -------------------- <br /> ------------- <br /> I <br /> ssDEPARTMENT U E ONLY <br /> Application Accepted By �L' Date IL �� dOdo Area -'/ % Employee ID# <br /> Grout Inspection By Date .J SPECIAL Well Permit <br /> Pump Inspection By (C 1 _,�,•,.- 1� , Date_ k�l 12s �1:Ji 1 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#! Amount W <br /> Codes Info Cash Remitted Date4SirAic,eRe u �Invoice# Well ID# <br /> EHD d3-0e 6/1711079 <br /> WELL/PUMP PERMIT <br />