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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468-3420 <br /> NON-REFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOBADDREss 843c) LealP AvI= CnvIZIP-Stockton,CA 95212 <br /> CROSS STREET Franco Ave APN 08532004 PARCEL SIZE LANo USE APPLICATION# O <br /> A <br /> OWNER NAME PAI11 TnVnttl PHONE ra <br /> OWNER ADDRESS _ 8439 Teale Ave CrTY/STATEIZIP Stockton,C'A 95212 <br /> CONTRACTOR Purviance Drillers, INC PHOPIE209-887-3554 <br /> CONTRACTOR ADDRESS P-0- BOX 64 CITyISTATE/ZIPLi nden CA 95236 <br /> SUBCONTRACTORICONSULTANT PHONE <br /> SUBCONTRACTORICONSULTANT ADDRESS CITY/STATE/LP <br /> LICENSE $C-57 :-C-61 7 D-09 :'i Other NUMBER 377923 EXPIRATION DATE 7/31/21 <br /> BILLING PARTY: i-OWNER '-1 CONTRACTOR 11 SUSCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING:t,General Mineral/Coliform Bacteria(4391)u Dibromochloropropane(4392)G Arsenic(4393) <br /> INTENDED USE Pomestic/Private L Irrigation/Agricultural L Industrial :i Water Quality Monitoring Ci Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK C New Well G Replacement Well a Well Alteration/Modification ❑Other <br /> Monitoring Well(s) #of wells ❑Soil Bor ng(s) #of borings F,Geotechnical_#of borings <br /> Out-0f-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> New Pum C Pump Replacement &ump Repair w C Raise Well Casing <br /> WELL CONSTRUCTION ,�yXytin6�J <br /> Drilling Method Mud Rotary E Air Rotary =Auger F:Cable Tool .Push Point : Other <br /> Proposed Well Depth ft Excavation in diameter ❑Open Bottom U Gravel Pack/Gravel Size in diameter <br /> C Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched :1 Steel U Plastic ❑Stainless Steel :3 Other <br /> Grout Seal Depth ft Neat Cement(94 lb bag/r10 gal water) C Sand Cement sack mb:f7 gal water <br /> 1.Bentonite(20%solids) D Other <br /> Grout Placement Method Pumped -Free Fall L Other E Retardant/Accelerator(name) <br /> PEDESTAL Installed By �Driller L Pump Contractor L Other <br /> L Concrete Pedestal LDimensions:Width ft Length It Thick in E Christy Box a Stove Pipe <br /> PUMP VSubmersible7i Turbine D Other HP Pump Set 13FsIt 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 !r V NCS?vCYTICE REQUIRE?.. 99 � :IQ*lG-PLEASE Cha 9,!2n9} <br /> SIGNED LCLGCC ,�(/L!/+Q7k,{J TITLE dL-P ..J ��-7 DATE 11 /2 20 z. <br /> I <br /> T <br /> CE jVE6 <br /> i <br /> 1132020 <br /> /N COU <br /> DEPARTMENT USE ONLY PARTTAL � <br /> Application Accepted By ���L Date 1I /S ,RV-QArea r� ��C� Employee ID# <br /> Grout Inspection By Date_ Ll SPECIAL Well Permit <br /> r <br /> Pump Inspection By ^,.;\ ; (�_(�,�yt Q�,.: Date_ 1 1�L D WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Check#/ Amount Permit/Codes Info B Invoice# Well ID# <br /> Cash Remitted Date Sep, R e # <br /> 03-0 477 q q <br /> n <br /> EHD 43-06 6/11rto19 <br /> WELL/PUMP PERMIT <br />