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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1866 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 /> JOBADDRESS 47(.45 ShLi-ppee Ln Cm'/ZIP Stockton 95212 m <br /> CROSS STREET -/(]/ l�f Gr)7aLj�. �Q APN 053001q PARCEL SIZE •rf(1 LAND USE APPLICATION# O <br /> A <br /> OWNERNAME Bary Blythe PHONE rWn <br /> OWNERADDRESS 4745 Shippee Ln clrrlsTATEmp Stockton,Ca 95212 <br /> CONTRACTOR Purviance Drillers, INC PHONE209-887-3554 <br /> CONTRACTOR ADDRESS P-0- BOX 64 CITYISTATE/ZIPLinden CA 95236 <br /> SUBCONTRACTORICONSULTANT PHONE <br /> SUBCONTRACTORICONSULTANT ADDRESS CrrY/STATEIMP <br /> LICENSE k C-57 7 C-61 D-09 Other NUMBER 377923 EXPIRATION DATE 7/3 1/2 1 <br /> BILLING PARTY: OWNER CONTRACTOR _ SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING:['General Mineral/Coliform Bacteria(4391) 1 Dibromochloropropane(4392)C Arsenic(4393) <br /> INTENDED USE DOmeStiC/Phvate ii Irrigation/Agricultural C Industrial ;;Water Quality Monitoring ;;Soil Sampling/Charactenzation <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 C Well Alteration/Modification f I Other <br /> MonitoringWell(s) #of wells SailBoring(s) ttorbo"ngs UGeotechnical #otborings <br /> Out-Of-Service Well G Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pum )<Pump Replacement I Pump Repair _Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary C Auger :_Cable Tool Push Point 7 Other <br /> Proposed Well Depth ft Excavation in diameter 7 Open Bottom �Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched 'Steel Plastic Stainless Steel .I Other <br /> Grout Seal Depth ft Neat Cement(94 lb bag/5-10 gal water) Sand Cement Sack mixf7 gal water <br /> Bentonite(20%solids) D Other <br /> Grout Placement Method Pumped _I Free Fall C Other -Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller --Pump Contractor L Other <br /> Concrete Pedestal':Dimensions:Width It Length ft Thick in ":Christy Box a Stove Pipe <br /> PUMP Submersible;!Turbine C1 Other HP-Lt-7 Pump Set /00 It 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 I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> +;DVANCE NOTiC_REQUIRED Fi 7NS-P)_.EASE CALL.f?.()9)095,(75.?2 <br /> SIGNED �(�}`.(/ '�'�—L TfTLE /%�.J Gr"��-rte-/ DATE <br /> i <br /> \1 <br /> F�Nr <br /> -44t --- ------ �AFD <br /> 9 2020 <br /> D U/N <br /> pgRTouNTy <br /> I MENT <br /> I I MJI -- <br /> , .. <br /> DEPARTMENT USE ONLY <br /> Application Accepted By ��/` �-` Date %e: o0 0 Area y �/ Employee ID# C'K <br /> Grout Inspection By Date C1 SPECIAL Well Permit <br /> Pump Inspection By Y'D A4, 5lti l jtjL Date \ 4 12,+1�A 7 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Permit/ <br /> Codes Info B ash Remitted Date Service Request# Invoice# Well ID# <br /> y3$1 o�u LkJNO <br /> EHD43-06 61112019 WELL!PUMP PERMIT <br />