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WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468-3420 <br /> NON-REFUNDABLE PERMIT www.sigov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> AveO�/MPStockton 95207 N <br /> JOB ADDRESS 1422 Meadow m <br /> vl. _ <br /> CROSSSTREET Pershing Ave APN t9/�35 PARCEL SIZE LAND USE APPLICATION# p <br /> A <br /> OWNERNAME Mary wolf PHONE209-915-0661 y <br /> OWNERADDRESS 1448 Meadow Ave CITYISTATEMPStockton CA 95207 <br /> CONTRACTOR Purviance Drillers r INC PHONE209-887-3554 <br /> CONTRACTOR ADDRESS P-0- BOX 64 CrY/STATE/ZpLinden CA 95236 <br /> SUBcoNTRACTORICONSULTANT PHONE <br /> SUBCONTRACTORICONSULTANT ADDRESS CITY/STATE/ZIP <br /> LICENSE A C-57 S C-61 D-09 i-'Other NUMBER j l�Gr�� EXPIRATION DATE <br /> BILLING PARTY: G OWNER "'.CONTRACTOR C SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:1'General Mineral/Coliform Bacteria(4391)'1 Dibromochloropropane(4392)L Arsenic(4393) <br /> INTENDED USE p DomesticlPrivate --Irrigation/Agricultural Industrial ❑Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well C Replacement Well -;Well Alteration/Modification I Other <br /> - Monitoring Weli(s) #of wells ❑Soil Borings) #of borings ;7 Geotechnical of borings <br /> Out-Of--Service Well G Out-Of-Service Well Renewal I i Cross-Connection Repair <br /> New Pump yt Pump Replacement ❑Pump Repair 7 Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method :: Mud Rotary :Air Rotary f:Auger Cable Tool E Push Point Other <br /> Proposed Well Depth ft Excavation in diameter 71 Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth R <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched 0 Steel i7 Plastic N Stainless Steel C.1 Other <br /> Grout Seal Depth ft LI Neat Cement(941b bagIS-10 gal water) a Sand Cement sack mixr7 gal water <br /> =Bentonite(20%solids) D Other <br /> Grout Placement Method Pumped '_Free Fall L Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller _:Pump Contractor C Other <br /> -Concrete Pedestal CDimensions:Width ft Length It Thick in ;Christy Box _Stove Pipe <br /> .PUMP F SubmersibleG Turbine -;Other HP Pump Set R Standing Water Level ft <br /> I 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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> .:' CE P7,r c <br /> T: <br /> SIGNED .LI Gf?-a�c.L- ^TITLE <br /> DATE //07✓ <br /> AYMENT <br /> q CEIVED <br /> LZ42010 <br /> O QUIN COUNTY <br /> IVI �O MAENTAL <br /> RTMENT <br /> I <br /> DEPARTMENTUSEONLY 1 <br /> Application Accepted By /'—/� Date ! a�Oc7J Area " .16; Employee ID# 1 <br /> Grout Inspection By Date q ❑ SPECIAL Well Permit <br /> Pump Inspection By r�/ Date / =I WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Check#/ Amount Date Permit/ <br /> Codes Info Cash Remitted Service Re uest# Invoice# Well ID# <br /> EHD 43-06 8l17/2019 ^/ / <br /> l WELL!PUMP PERMIT <br />