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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKT40N CA 95205-6232(209)4683420 <br /> NON-REFUNDABLE PERMIT www.s*-qov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOBADDRESS 12828 R Ri crht Mi 1 a Ed CITY/ZP Stockton (521 2 ,m <br /> CROSSSTREET Jackton:_Rd ApN 08915005 pARCELSZE 5(t, LAND USE APPLICATION# o <br /> OWNERNAME Joe Baalietto m <br /> PHONE <br /> IOWNERADDRESS 301 S- Al7rQj:a CITY/STATE/ZIPStOCkton, CA 95203 <br /> CONTRACTOR Purviance Drillers, INC PHONE209-887-3554 <br /> CONTRACTOR ADDRESS P-0- BOX 64 CITY/STATE21PLinden CA 95236 <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTORICONSULTANT ADDRESS Cr Y1STATE/ZIP <br /> LICENSE k C-57 C-61 i D-09 iJ Other NUMBER 377923 EXPIRATION DATE 7/3T/21 <br /> BILLING PARTY: :1 OWNER L CONTRACTOR _1 SU8CON7RACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:G General Mineral/Coliform Bacteria(4391)❑Dibromochloropropane(4392)G Arsenic(4393) <br /> INTENDED USE Domestic/Private rrigatioNAglicultural ;: Industrial ':Water Quality Monitoring 7 Soil Sampling/Characterization <br /> Public Water System <br /> H different from Owner Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ❑New Well Replacement Well U Well Alteration/Modification i;Other <br /> C Monitoring Well(s) #of wells Soil Boring(s) obor #or borings <br /> # f ings (;GeotechnigiYM <br /> C Out-Of-Service Well C Out-Of-Service Well Renewal G Cross-Connection Repair <br /> C New Pump ump Replacement _:Pump Repair ::Raise Well Casing <br /> WELL CONSTRUCTION v CD <br /> Drilling Method Mud Rotary Air Rotary I i Auger Cable Tool Push Point 7 Other OC <br /> Proposed Well Depth ft Excavation in diameter ❑Open Bottom C Gravel Pack/Gravel Size Iameter 200 <br /> C Conductor Casing In diameter / Conductor Casing Depth ft JOA <br /> Well Casing Diameter- In Thickness/Gauge/ASTM Schad Steel D Plastic I i Stainless Steel L Other ENVY USN o <br /> Grout Seal Depth ft ;I Neat Cement(94 Ib bag15-10 gal water) C Sand Cement sack mix/7 ga t4D P f <br /> L Bentonite(20%solids) J Other q RT <br /> Grout Placement Method G Pumped D Free Fall L Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By =Driller L:Pump Contractor G Other <br /> Concrete Pedestal CDimensions:Width ft Length ft Thick In �_j Christy Box II Stove Pipe <br /> PUMP Submersible!Turbine G Other HP�_ Pump Set It Standing Water Level _ft <br /> I HEREBY CERTIFY THAT I HAVE 15REPARED 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 /> WORKERS COMPENSATION LAWS. <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT IAM IN COMPLIANCE WITH ALL <br /> �)i3F2 ADVANCE NOTICE REQUIRED FOR INSP .CIT:'p18-PLEASE r'ALl-r2nnl <br /> SIGNED <br /> �Q U �/LCti1 Gltz TITLE <br /> DATE <br /> l <br /> ------------------------ <br /> 1 3 <br /> DEPARTMENT USE ONLY <br /> � v <br /> Application Accepted By Date Area Employee ID# <br /> Grout Inspection By Date_ ❑ SPECIAL Well Permit <br /> Pump Inspection By. Cy-L=S,,V L_ �rZl 1 Date �L �'\)ti'w -1 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Permit/ <br /> Codes Info sh Remitted Date Mce Re # Invoke# Well ID# <br /> EHD 43-06 611112019 <br /> WELL/PUMPPERMIT <br />