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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468-420 <br /> NON-REFUNDABLE PERMIT www.si-ciov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 4 11 1 N Fin e Rd CrrY/ZIP Linden,CA 95236 y <br /> m <br /> CROSS STREET Flood Rd APN 1 0 5 2 5 0 0 4 PARCEL SIZE �•i "LAND USE APPLICATION# p <br /> OWNER NAME /r i,s !f tr_ ! �'/ m <br /> -�� � t'mrc'Yr� PHONE m <br /> N <br /> OWNER ADDRESS 7r,n7 N nod®sta T.n CrrY/STATFJZIP Lin. den.CA 95236 <br /> CONTRACTOR Purviance Drillers, INC PIINE209-887-3554 <br /> CONTRACTOR ADDRESS P-0. BOX 64 CITYISTATE/7JPLinden CA 95236 <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTORICONSULTANT ADDRESS CITY/STATEIZIP <br /> LICENSE X 457 C-61 I-D-09 ❑Other NUMBER 377923 EXPIRATION DATE 7/3 1/2 1 <br /> BILLING PARTY: _OWNER :i CONTRACTOR :.i SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELLSAMPUNG:G General MinerallColiform Bacteria(4391)[1 Dibromochloropropane(4392)[1 Arsenic(4393) <br /> INTENDED USE ❑DomeStiC/PriVate Irrigation/Agricultural ❑Industrial C Water Quality Monitoring C Soil Sampling/Characterization <br /> C Public Water System A <br /> H different from Owner. Water System Name Contact Name or Phone Number ^ <br /> TYPE OF WORK 0 New Well 1-.Replacement Well Well AReration/Modfication C Other `N <br /> _1 Monitoring Well(s) #of wells C SOif Borin ttof borings p of borin s V� <br /> 9(s) a Geotechnical 9 D <br /> Out-0f-Service Well �Out-Of-Service Well Renewal Cross-Connection Repair OCT <br /> Casin New Pum is Pum Re acement Pum n <br /> Repair Raise Well , <br /> WELL CONSTRUCTION <br /> Drilling Method ^AI 1/0,4 g ?�?0 <br /> Mud Rotary Air Rotary n Auger -Cable Tool Push Point [; Other ^I'V 0q <br /> Proposed Well Depth ft Excavation in diameter 7 Open Bottom ❑Gravel Pack/Gravel Size ri <br /> QtCtarn l�NO ANT y <br /> Conductor Casing in diameter / Conductor Casing Depth g 7 <br /> Well Casing Diameter_In Thickness/Gauge/ASTM Schad 71 Steel r Plastic 1]Stainless Steel a Other T MENT <br /> Grout Seal Depth ft I Neat Cement(941b bag/510 gal water) ri Sand Cement sack mix17 gal water <br /> Bentonite(20%solids) D Other <br /> Grout Placement Method Pumped L:Free Fall U Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By C Driller C Pump Contractor L] Other <br /> i 1 Concrete Pedestal❑Dimensions:Width ft Length It Thick in D Christy Box ❑Stove Pipe <br /> PUMP U Submersible Turbine :f]Other HP Pump Set ft Standing Water Level <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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> rANCE N^TICE REQt11RF..^. F,_.n '1cnEn I ,ix rat c^ r_r� nn,n <br /> SIGNED r2^GAG G -__S% T 1611 <br /> ^ <br /> TITLE ```����'��� DATE Q��U <br /> O <br /> DEPARTMENT USE ONLY <br /> Application Accepted By ��� Date 1 "t •;: Area Employee ID# <br /> Grout Inspection By Date 1 SPECIAL Well Permit <br /> Pump Inspection By S t u -. I Date JL I Z! -. I, D WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Permit/ <br /> Codes Info Cash Remitted Date Se ce Re uest# Invoice# Well ID# <br /> EHD43-06 8177/2079 <br /> 1/S 7D12_o3 wELL/PUMP PERMIT <br />