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WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)4U-3420 <br /> NON-REFUNDABLE PERMIT www.S ov orglehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOBADDREss 8000 N Podesta Ln <br /> CITY/2,PLinden,CA 95236 � <br /> CROSSSTREET Podesta Ln APN 09135027D <br /> PARCEL SIZE _LAND USE APPLICATION# v <br /> v <br /> a <br /> OWNER NAME Podesta, cel"I(j <br /> ---� PHONE y <br /> OWNERADDRESS 8000 N Podesta Ln CITY/STATE/ZI ,CA 95236 <br /> CONTRACTOR Purviance Drillers, INC PHONE209-887-3554 <br /> CONTRACTOR ADDRESS P.0- BOX 64 CTrY/STATE21PLlnden CA 95236 <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/LP <br /> LICENSE �tC-57 C-61 ['.D-09 i'Other NUMBER 377923 EXPIRATION DATE 7/31/21 <br /> BILLING PARTY: :-i OWNER ::CONTRACTOR 11SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:C General Mineral/Coliform Bacteria(4391)❑Dibromochioropropane(4392)11 Arsenic(4393) <br /> INTENDED USE Domestic/Private D Irrigation/Agricultural " Industrial i-'Water Quality Monitoring (,SOil Sampling/Characterization P <br /> L Public Water System <br /> H Eiifemnt from Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK C New Weil C Replacement Well D Well Alteration/Modification C Other <br /> C Monitoring Well(s) #of wells 0 Soil Boring(S) #ot borings #of borin s <br /> �Geotechnical g <br /> Out-Of-Service Well Out-Cf-Service Well Renewal [i Cross-Connection Repair , <br /> D New Pum .Pump Replacement '4Pump Repair L Raise Well Casing ?O2o <br /> WELL CONSTRUCTION CA/ q QU/N <br /> Drilling Method ::Mud Rotary Air Rotary L Auger ::Cable Tool :Push Point C Other ��rIN COONT y <br /> Proposed Well Depth ft Excavation in diameter ;]Open Bottom r Gravel Pack/Gravel Size n diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft RTMENT <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched ']Steel ❑Plastic L Stainless Steel ❑Other <br /> Grout Seal Depth ft Neat Cement(94 Ib bag/5-10 gal water) C Sand Cement sack mixr7 gal water <br /> Bentonite(20%solids) C Other <br /> Grout Placement Method ']Pumped Ll Free Fall L Other -I Retardant/Accelerator(name) <br /> PEDESTAL Installed By C Driller D Pump Contractor L Other <br /> Concrete Pedestal UDimensions:Width ft Length ft Thick in ::Christy Box ❑Stove Pipe <br /> PUMP ubmersibleD Turbine D Other HP Pump Set Z-ft Standing Water Level 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 LAWS. <br /> g I R ADVANCE NOTICE REQUIRED FOR INSi3 701 1S-P'7ASE r^at_i./2nd%t <br /> SIGNED TITLE(,f/ - TITLE <br /> DATE 10114/702D <br /> ------------- <br /> -------------------------------- - <br /> --------------------------- <br /> . e <br /> DEPARTMENT USE ONLY <br /> Application Accepted By��1 Date 'J C" .UJtJ Area C EmployeelD# _ <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump inspection By.� l';ZU. 4%' Date -1 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ry <br /> COMMENTS <br /> PE SC Received Check#/ Amount PermiU <br /> Codes Info ash Remitted Date Service Re uest# Invoice# Well ID# <br /> I . <br /> - EHD 0306 &1t/2019 �}I}/� <br /> ' 'fJ IIS��/ �� WELL/PUMP PERMIT <br />