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WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468.3420 <br /> NONwREFUNDABLE PERMIT WWW.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> y <br /> JOB ADDRESS 20550 E Kettleman Ln CITYIZIPTtnr] i , CA 95240 m <br /> a <br /> CROSS STREET Clements APN 05318015 PARCEL S¢E1 LAND USE APPLICATION # o <br /> OWNER NAME Shawn Wentzel <br /> PHONE 00 <br /> ul <br /> OWNER ADDRESS 20550 E Kettleman Ln CrrY/STATE21P�pol , i". A 95240 <br /> CONTRACTOR Purviance Drillers , INC pHoroe209 - 887 - 3554 <br /> CONTRACTOR ADDRESS P • 0 • BOX 64 CnygsTATEMPLinden CA 95236 <br /> SUBCONTRACTORICONSULTANT PHONE <br /> SUBCONTRACTORICONSULTANT ADDRESS CITY/STATE/ZIP <br /> LICENSE XC-57 i C-61 D-09 a Other NUMBER 377923 EnPIRATIDNDATE 7 / 31 / 21 <br /> BILLING PARTY: ❑ OWNER ❑ CONTRACTOR a SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELLSAMPLING: C General Mineral/Coliform Bacteria (4391 ) Ll Dibromochloropropane (4392) 0 Arsenic (4393) <br /> INTENDED USE DomestictPrivate C Irrigation/Agricultural G Industrial C Water Quality Monitoring C Soil Sampling/Characterization <br /> D Public Water System q y <br /> If different from Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK C New Well ❑ Replacement Well C Well Alteration/Modification El Other ` C® <br /> 7 Monitoring Well(s) # Of wells ❑ Soil Boring(s) z of borings gs C Geotechnical of borings <br /> C Out-Of-Service Well ; Out-Of-Service Well Renewal G Cross-Connection Repair D <br /> C New Pum ump Replacement C Pump Repair G Raise Well CasingO 20�� <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary C Auger C Cable Tool C Push Point L Other PEIE�lvV/ u)/Pv CD <br /> Proposed Well Depth ft Excavation in diameter D Open Bottom C Gravel Pack/Gravel Size in diameter EPA R rq�NTy <br /> LJ Conductor Casing in diameter / Conductor Casing Depth ft N � <br /> Well Casing Diameter _ in ThicknesslGauge/ASTM Schad ❑ Steel C Plastic LI Stainless Steel ❑ Other <br /> Grout Seal Depthft C Neat Cement (94 lb bag/5-10 gal water) C Sand Cement sack mixl7 gal water <br /> Bentonite (20% solids) O Other <br /> Grout Placement Method �i Pumped Free Fall C Other G Retardant I Accelerator (name) <br /> PEDESTAL Installed By ❑ Driller zi Pump Contractor G Other <br /> C Concrete Pedestal ❑Dimensions: Width ft Length ftThick in C Christy Box C Stove Pipe <br /> PUMP Submersible ❑ Turbin6 ❑ Other . HP S Pump Set ft Standing Water Level .2La.LL, ft <br /> I HEREBY CERTIFY THAT I HAVE PREPAREDTHIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. 1 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 /> rv�JtJI 3_- PLEASE CA F_ <br /> SIGN Df 04? TITLE J;�S2' ! _ _ DATE <br /> 1 <br /> iL <br /> ETT <br /> a Iltti <br /> DEPARTMENT USE ONLY <br /> Application Accepted BY — Date AreaU "ry n <br /> Employee 1D# <br /> Grout Inspection By Date 1 ❑ SPECIALWell Permit <br /> Pump Inspection By i'lj\[ S (?. ,+:4 ,u , x�_ Date :1 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Check#1 Amount Permit/ <br /> Codes Info Cash Remitted Date erviee Re oast # Invoice # Well ID# <br /> EHD 43-06 6/1 112019 WELL /PUMP PERMIT <br />