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CONTRACTOR Purviance Drillers, INC <br />CONTRACTOR ADDRESS P.O. Box 64 <br />SUBCONTRACTOPJCONSULTANT <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />ro,2 O 9 _887_3554 <br />cmisTATEmpLinden CA 9 5 2 3 6 <br />PHONE <br />CITY/STATE/ZIP <br />CONTRACTOR SUBCONTRACTOR/CONSULTANT BILLING PARTY: OWNER <br />Replacement Well 0 Well Alteration/Modification Other TYPE OF WORK New Well <br />PEDESTAL Installed By '2 Driller H Pump Contractor C Other <br />. Concrete Pedestal L1Dimensions: Width ft Length ft Thick in Christy Box 2 Stove Pipe <br />XSubmersible Turbine Other Pump Set ‘-1 ft Standing Water Level qt-t -5 ft PUMP HP <br />WELL /PUMP PERMIT EHD 43-06 6111/2019 <br />DATE / <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Ms EAST BraELroN AVENUE - SrocicroN CA95205 -6232 (209)468-3420 <br />NON-REFUNDABLE PERMIT www.slgoy.orgiehd EXPIRES 1 YEAR FROM DATE ISSUED <br />DOMESTIC WELL SAMPLING: r. General Mineral/Coliform Bacteria (4391): Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE /Domestic/Private H Irrigation/Agricultural H Industrial H Water Quality Monitoring H Soil Sampling/Characterization <br />_ Public Water System <br />If different from Owner <br />- Monitoring Well(s) # of wells : Soil Boring(s) #01 borings : Geotechnical <br />. ; Out-Of-Service Well : Out-Of-Service Well Renewal ti Cross-Connection Repair <br />ri New Pump )Pump ReplacementE.: Pump Repair H. Raise Well Casing <br />WELL, CONSTRUCTON <br />Drilling Method J Mud Rotary : Air Rotary ._. Auger 7 Cable Toot .2 Push Point ..; Other <br />Proposed Well Depth ft Excavation in diameter H Open Bottom Ii Gravel Pack/Gravel Size in diameter <br />H Conducbor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched 1: Steel i; Plastic Li Stainless Steel H Other <br />Grout Seal Depth ft : Neat Cement (94 lb bag/5-10 gel water) C Sand Cement <br />.._. Bentonite (20% solids) 0 Other <br />Grout Placement Method •_: Pumped Li Free Fall t: Other <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 />SIGNEDc_ PO-14-6 <br />2 r,'E NOTICE REr INE7 <br />PE <br />Codes <br />SC <br />Info <br />Received <br />Jac, <br />Check/l/ <br />Cash <br />Amount <br />Remitted as Data Permit! <br />aumt # Invoice # Well ID# <br />17 I .5a-- f 77 I -1/-Y 1 <br />ft <br />iri0-t Ore M <br />Water System Name <br />Retardant / Accelerator (name) <br />Contact Name or Phone Number <br />sack mix/7 gal water <br />of borings :SS3210CIV 3119 JOB ADDRESS 25879 N Cherokee Rd. Cry/Zip c: a 11- CA 9/Y17 <br />CROSS STREET Collier Rd APN 0 0 5 3 9 0 3 8 PARCEL SIZE LAND USE APPUCATION # <br />OWNER NAME Shelley Wei ntraith PHONE <br />owNER ADoREss 2 58 79 N Cherokee Rd CITY/STATE/ZIP r1/- CA clA32 <br />LICENSE k C-57 C-61 _ 0-09 Other NUMBER 377923 EXPIRATION DATE 7/31/21