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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)4683420 <br /> NON-REFUNDABLE PERMIT www.siciov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 20034 E. Flood Rd C,Tv/2,P Linden,CA 95236 <br /> In <br /> CROSS STREET N. Flood Rd APN 10519025 c <br /> PARCEL SIZE LAND USE APPLICATION# p <br /> OWNER NAME Lawerance Sambado F,,I— 1-cmir(-4J (;nle;fir:jeS PHONE <br /> OWNER ADDRESS P.O BOX 461 Crry/STATEIMP Linden,CA 95236 <br /> CONTRACTOR Purviance Drillers, INC PHONE209-887-3554 <br /> CONTRACTOR ADDRESS P-0- BOX 64 CIN/STATE/ZIPLinden CA 95236 <br /> SUBCONTRACTORICONSULTANT PHONE <br /> SUBCONTRACTORICONSULTANT ADDRESS CITY/STA7E/7JP <br /> LICENSE k C-57 L'C-61 L 1 D-09 D Othef NUMBER 377923 EXPIRATION DATE 7 3 1 2 1 <br /> BILLING PARTY: OWNER D CONTRACTOR '-I SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING:G General Mineral/Coliform Bacteria(4391)0 Dibromochloropropane(4392)0 Arsenic(4393) <br /> INTENDED USE Domestic/Private rrigation/Agricultural U Industrial Water Quality Monitoring 11 Soil Sampling/Characterization <br /> Public Water System Y <br /> If different from Owner. Water System Name Contact Name or Phone Number <br /> :A I <br /> TYPE OF WORK _ New Well E Replacement Well Well Alteration/Modification D Other C�c� N <br /> Monitoring Well(s) #Of wells Soil Barin s #of borings #ofbodn s D <br /> 9O C;Geotechnical 9 <br /> Out-Of-Service ell Out-Of-Service Well Renewal 1.1 Cross-Connection Repair <br /> New Pump <br /> -_)CPum2 Replacement _Pump Repair E Raise Well Casing / <br /> UCTION �O?O <br /> WELL CONSTR <br /> Drilling Method : Mud Rotary Air Rotary -1Auger Cable Tool C Push Point Other_ H CNV/R /N CO <br /> Proposed Well Depth ft Excavation In diameter D Open Bottom E Gravel Pack/Gravel Size in dia a MFNr�NrY <br /> Conductor Casing in diameter / Conductor Casing Depth ft gRTn <br /> I Well Casing Diameter_In Thickness/Gauge/ASTM Schad Steel C Plastic r1 Stainless Steel i I Other NT <br /> Grout Seal Depth ft C Neat Cement(94 Ib bag/5-10 gal water) Sand Cement sack mW7 gal Water <br /> Bentonite(20%solids) ❑Other <br /> Grout Placement Method 1.Pumped Li Free Fall U Other :'i Retardant/Accelerator(name) <br /> PEDESTAL Installed By 2 Driller G Pump Contractor U Other <br /> Concrete Pedestal(-Dimensions:Width ft Length ft Thick in ❑Christy Box Stove Pipe <br /> PUMP Submersible Turbine :7 Other HP Pump Set ft Standing Water Level ft <br /> I HEREBY CERTIFY THAT 1 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 /> -r'ANC h3f)Y'CF R!=,7u iIY t+a I <br /> TITLE ^rrr. •n..�,�+_n. -. r r r-.:....r t, <br /> r <br /> SIGNED - 'L- '-' <br /> DATE )Z3 <br /> ------------------------------ <br /> --------------------------------- i <br /> d <br /> t <br /> DEPARTMENT USE ONLY <br /> Application Accepted ByDate J 3 doa-DC'C' <br /> Area � f � Employee ID# ) <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By t✓\t ) �e Data �1Y ����..a ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Permitt <br /> Codes Info Cash Remitted Date ce Re ues Invoice# Well ID# <br /> 6 <br /> EHD43-06 6111r1019 <br /> per, / I 3 I 7 WELL/PUMP PERMIT <br />