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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.Sigov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOBADDRESS 8657 Walnut Ar,- RD CfTY/ZlP qt n mkt CA Q Cn <br /> m <br /> shi ---- ar21a <br /> CROSS STREET epee Ln APN 08527001 PARCELSIZE' - PPLICATION# o <br /> LAND USE A <br /> O <br /> Andrea Cotta m <br /> OWNER NAME PHONE y <br /> N <br /> OWNER ADDRESS _ 8657 Wal n1,f- Ar es Rfl CITY/STATE/ZJP Stnnktnn ('A 95212 <br /> CONTRA6tOR Purviance Drillers INC PHONE 2 0 9-8 8 7-3 S 5 4 <br /> CONTRACTOR ADDRESS P.O. BOX 64 _ CITY/STATEJZPLinden CA 95236 <br /> SUBCONTRACTOR(CONSULTANT PHONE <br /> SUBCONTRACTORICONSULTANT ADDRESS CITY/STATE/ZIP <br /> LICENSE X C-57 =C-61 D-09 Other NUMBER 377923 EXPIRATION DATE 7/31/21 <br /> BILLING PARTY: OWNER :1 CONTRACTOR ,j SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING C General Mineral/Coliform Bacteria(4391).1;Qibromochloropropane(4392)G Arsenic(4393) <br /> INTENDED USE Domestic/Private Ci Irrigation/Agricultural J Industrial C:Water Quality Monitoring I I Soil Sampling=�R�er � <br /> zation <br /> =Public Water System <br /> If rbNerenl from Owner. Water System Name Contac Name or Phone <br /> TYPE OF WORK ;;New Well r Replacement Well 7 Well Alteration/Modfication C Other <br /> Monitoring Well(s) #of wells C Soil Boring(s) x of Wrings Geotechnical :or bonngs <br /> Out-Of-Service Well r Out-Of-Service Well Renewal a Cross-Connection Repair <br /> New Pump Wump Replacement '_PUMP Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary J Auger J Cable Tool Push Point 7 Other <br /> Proposed Weil Depth ft Excavation in diameter i Open Bottom ❑Gravel PackiGravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth g <br /> Well Casing Diameter,_in Thickness/Gauge/ASTM Sched i Steel fl Plastic 'I Stainless Steel ❑Other <br /> Grout Seal Depth ft _Neat Cement(941b bag/5-10 gal water) Sand Cement sack mix17 gal water <br /> L Bentonite(20%solids) J Other <br /> Grout Placement Method -- Pumped Ci Free Fall i.Other C:Retardant/Accelerator(name) <br /> PEDESTAL Installed By J Driller Z�Pump Contractor L Other <br /> C Concrete Pedestal❑Dimensions:Width ft Length ft Thick In Christy Box is Stove Pipe <br /> PUMP ` Submersible,-Turbine E Other HP ) Pump Set e c v <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 /> ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL (211 0 3-76c;, i <br /> SIGNED \� .�,[1_.:,{.,� �b%!,n..,asit:'� TITLE DATE------------ <br /> /1 r2 2020 <br /> --------- miff ---------- <br /> u <br /> V <br /> cZEST <br /> VED <br /> 3 2020 <br /> QUI/V <br /> f 01VlyEtiTUN1Y <br /> EPgRTM NT <br /> // AL <br /> DEPARTMENT USE ONLY <br /> Application Accepted By �Lf Date 3 Area <br /> Employee ID# I. <br /> Grout Inspection By Date LJ SPECIAL Well Permit <br /> Pump Inspection By e. j'1 t y L Date l( 1 I-- -1 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount PenNtif <br /> Codes In <br /> 8 ash Remitted Date $ R uestB Invoice# WellID# <br /> EHO43-M 6MIrA19 <br /> WELL/PUMP PERMIT <br />