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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.S ov.orlehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> rn <br /> JOB ADDRESS 20550 E Kettleman Ln CITY1ZIPl,nrli , CA 95240 m <br /> ,,cc a <br /> CROSS STREET Clements APN 05318015 PARCEL SIZE CGG 3 ; 13LAND USE APPLICATION # o <br /> m <br /> OWNER NAME Shawn Wentzel PHONE ai <br /> OWNERADDRESS 20550 E Kettleman Ln CITY/STATE/ZIP Ton (] i CA 95240 <br /> CONTRACTOR Purviance Drillers , INC PHONe209 - 887 - 3554 <br /> CONTRACTOR ADDRESSP • O . Box 64 CtrrlSTATE/zlPLinden CA 95236 <br /> SUBCONTRACTORICONSULTANT PHONE <br /> SUBCONTRACTORICONSULTANT ADDRESS CITY/STATE21P <br /> LICENSE X C-57 C-61 D-09 L' Other NUMBER 377923 EXPIRATION DATE 7 / 31 / 21 <br /> BILLING PARTY: C OWNER n CONTRACTOR v SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING : C General Mineral/Coliform Bacteria (4391 ) i.] Dibromochloropropane (4392) C] Arsenic (4393) <br /> INTENDED USEWOomesticlPrivate C Irrigation/Agricultural G Industrial C Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> ❑ Public Water System 4 <br /> If different from Omer. Water System Name Contact Name or Phone Number �C <br /> TYPE OF WORK ;; New Well L' Replacement Well ❑ Well Alteration/Modification ❑ Other Ic Ve►•I'1 <br /> Monitoring Well(s) # of wells Soil Boring(s) # ofbodngs C Geotechnical # ofbodngs <br /> Out-0f-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair Al 18 <br /> C New Pum um Replacement a Pum Repair ❑ Raise Well CasingZo? 9 <br /> WELL CONSTRUCTION , • rA / V/ Q ltv <br /> Drilling Method Mud Rotary ❑ Air Rotary G Auger ; Cable Toot _': Push Point ❑ Other FA I -r, ONMis�Nco �jv <br /> Proposed Well Depth ❑ft Excavation in diameter ❑ Open Bottom Gravel Pack/Gravel Size in diameter �/� Q <br /> Conductor Casing in diameter I Conductor Casing Depth ft AR jME� T <br /> Well Casing Diameter . in Thickness/Gauge/ASTM Sched :j Steel a Plastic U Stainless Steel C Other <br /> Grout Seal Depth It ] Neat Cement (94 Ib bag/540 gal water) C Sand Cement sack mrxR gal water <br /> L•o Bentonite (20% Solids) r Other <br /> Grout Placement Method ❑ Pumped ; Free Fall C Other C Retardant / Accelerator (name) <br /> PEDESTAL Installed By ❑ Driller _ Pump Contractor ❑ Other <br /> CI Concrete Pedestal Dimensions: Width ft Length ft Thick in h Christy Box C Stove Pipe <br /> PSubmersible . Turbin& ❑ Other . HP CS Pump Set (v � ft Standing Water Level 2 <br /> —UMP <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 IFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION WS <br /> SIGN DTITLE 4ZA"l " - - DATE <br /> • t <br /> A. <br /> N <br /> 4 <br /> i r Lid <br /> DEPARTMENT USE ONLY Q <br /> Application Accepted By Date 1 W ,5Area � CI Employee 1D# <br /> Grout Inspection By { Date ❑ SPECIAL Well Permit <br /> Pump Inspection By V rW\CZI,%*4 449 L Date " t. ❑ WAIVER Received <br /> Soil Boring inspection By Date Constructed Well Depth ff <br /> COMMENTS <br /> PE Sc Received Check#/ Amount Date Permitl Invoice # Well IDA <br /> Codes Info Cash Remitted Service Request # <br /> EHD 43A6 611172079 { ` ^ WELL /PUMP PERMIT <br />