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SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP <br />OWNER ADDRESS 17803 E. Baker Rd CITY/STATE/ZIP Linden , CA 99236 <br />CONTRACTOR p110i,209-887-3554 Purvianco Drillers, INC <br />cmdsTATEm pLinden CA 95236 c„ThAc-ro, ADDREss P 0 . BOX 64 <br />www.sjgov.orgiehd EXPIRES 1 YEAR FROM DATE ISSUED <br />17803 E. Baker Re1 CITY/Zip L'inclen, CA 9921F <br />Duncan Rd APN 09115022 PARCEL SIZE54.7 1 LAND USE APPUCATION <br />Antoinette cpilp <br />JOB ADDRESS <br />CROSS STREET <br />OWNER NAME <br />NON-REFUNDABLE PERMIT <br />PHONE <br />SUBCONTRACTOR/CONSULTANT PHONE <br />LICENSE 5-.( C-57 _ C-61 L: D-09Other NUMBER 377923 EXPIRATION DATE 7/31/21 2, <br />BILLING PARTY: - OWNER .7] CONTRACTOR SUBCONTRACTOR/CONSULTANT <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205-6232 (209) 466-3420 <br />ft <br />DOMESTIC WELL SAMPLING: C General Mineral/Coliform Bacteria (4391)1i Dibromochloropropane (4392) C Arsenic (4393) <br />INTENDED USE XDomestic/Privete 2 Irrigation/Agricultural E: Industrial : Water Quality Monitoring LI Soil Sampling/Characterization <br />'._ Public Water System <br />If Olffenant from Owner Water System Name Contact Name or Phone Number <br />TYPE OF WORK .. New Well : Replacement Well C Well Alteration/Modification L.: Other <br /> <br />WELL CONSTRUCTION <br />i : <br /> <br />414R 0 4 <br />Drilling Method :: Mud Rotary : Air Rotary 7 Auger : Cable Tool : Push Point L: Other - 2021 <br />Proposed Well Depth ft Excavation in diameter II Open Bottom El Gravel Pack/Gravel Size tAiltaile,4pCJ, Qt Jmi <br />. <br />of bo : Monitoring Well(s) <br /> <br />."0. New Pump ,)('Pump Replacement El Pump Repair Raise Well Casing <br /> <br />Out-Of-Service Well <br />4 of wells C Soil Boring(s) <br />C Out-Of-Service Well Renewal C Cross-Connection Repair <br />AI rings 17 Geotechnical # of borings <br />L.: Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched • : Steel : Plastic C Stainless Steel u Other <br />Grout Seal Depth ft : Neat Cement (94/b bag/5-10 gal water) '.- Sand Cement sack mlxI7 gal water <br /> <br />L.: Bentonite (20% solids) ,2 Other <br />Grout Placement Method : Pumped . : Free Fall i : Other : Retardant / Accelerator (name) <br />PEDESTAL Installed By C Driller LL Pump Contractor C Other <br />Concrete Pedestal -Dimensions: Width ft Length ft Thick in r Christy Box : Stove Pipe <br />PUMP )(Submersible C Turbine C Other HP Pump Set L -75 ft Standing Water Level 1\44 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 />SIGNED TITLE <br />..'."-1 '10717.: NOTICE REQUIR77 7-7 ;':?.? :!-t* - PLEASE (VI'. -7 —7-- <br />111 <br />DAM .2- -Z/-21 <br /> <br />Ci• <br /> <br />4;4 <br /> <br />DEPARTMENT USE ONLY <br /> <br />Application Accepted By Date Area Employee ID# <br /> <br />Grout Inspection By Date - I SPECIAL Well Permit <br />Pump Inspection By \ I 'L- 5i ':::' (s2-0,41- L Gi),,Laq Date ., El WAIVER Received <br /> <br />Soil Boring Inspection By Date Constructed Well Depth <br />COMMENTS <br />PE <br />Codes <br />SC <br />Info <br />Received <br />Bt, <br />Checlill <br />Cash <br />Amount <br />Remitted Date , <br />Permit/ <br />Servic Request # Invoice # Well ID, <br />,1.36 00 _ 4 l i ,1412) <br />, 1, ) <br />01- Li Lt C7 (0 o % <br />_ <br />_ A <br />. EHD 43-06 6/11/2019 <br />/2-0 4+7 ita <br /> WF_11 /PUMP PERMIT