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JOB ADDRESS 5301 Solari Ranch Rd onmp Stockton,CA 95215 <br />ciRossSTRErr Cherokee Ln ApN 0871 8240 PARCEL SIZE 1 . 52 LAND USE APPLICATION # <br /> <br />OwNERNmn Larry Payne <br /> <br />PHONE <br /> <br />OWNER ADDRESS _5301 Solari Ranch Rd CirrisTATemp Stockton,CA 95215 <br />CONTRACTOR Purviance Drillers, INC p,,209 -887 -3554 <br /> <br />P CONTRACTOR ADDRESS .O. Box 64 a,,/sT„mpLinden CA 95236 <br />SUBCONTRACTOR/CONSULTANT <br /> <br />PHONE <br />SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATEIZIP <br />LICENSE R C-57 rf: C-61 2 0-09 2 Other NUMBER 377923 EXPIRATION DATE 7/31/21 <br />BILLING PARTY: OWNER CONTRACTOR 1: SUBCONTRACTOR/CONSULTANT <br />INTENDED USE p,...Domestic./Private lnigation/Agricultural Industrial E Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />Water System Name If different from Owner Contact Name or Phone Number <br /> <br />17A17- <br /> THD wiEN TAL <br />COuvry <br />9 202/ <br />RTVE:E CINT <br />g: /\ <br />-a <br />SA <br />L. <br />v,A4) <br />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.orgiehd EXPIRES 1 YEAR FROM DATE ISSUED <br />DOMESTIC WELL SAMPLING: C General Mineral/Coliform Bacteria (4391) Et Dibromochloropropane (4392) C Arsenic (4393) <br />= New Well c Replacement Well E Wet AlteratiOn/Modification E Other <br />5 Monitoring Well(s) # of wells E Soil Boring(s) ft of borings E Geotechnical ft of borings <br />: Out-Of-Service Well LI Out-Of-Service Well Renewal :I Cross-Connection Repair <br />: New Pump : Pump Replacement 1)(Pump Repair I Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method I Mud Rotary I Air Rotary E Auger I Cable Tool ., Push Point Other <br />Proposed Well Depth ft Excavation in diameter n Open Bottom C Gravel Pack/Gravel Size in diameter <br /> <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched ' i Steel E Plastic E Stainless Steel I Other <br />Grout Seal Depth ft 7 Neat Cement (94 lb bag/5-10 gal water) I Sand Cement sack mix/7 gal water <br />C Bentonite (20% solids) Other <br />Grout Placement Method I Pumped I Free Fall E Other I Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller .7. Pump Contractor C Other <br />Concrete Pedestal ' :Dimensions: Width ft Length <br /> <br />ft Thick in t] Christy Box C Stove Pipe <br />PUMP Submersible: Turbine '.3 Other <br /> <br />HP I• 5 Pump Set ft Standing Water Level I 90 ft <br /> <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 COMPENS • N LAWS. <br />.AJRADVANCENO7iC.;EREQUIRED FORINSPEOTIONS -PLEASE CALL (2 <br /> TITLE Vri DATE ;- k ko* <br />DEPARTMENT USE ONLY <br />Z--- <br /> <br />Application Accepted By Date id? j 4 Area • Employee ICl/ <br /> <br />Grout Inspection By Date Ti SPECIAL Well Permit <br /> <br />Pump Inspection By '.\L) I Le. ; ikt:.1-L Date 14 1 61 I 1, '1 I 7.1 WAIVER Received <br />Constructed Well Depth ft <br />COMMENTS <br />PE <br />Codes <br />SC <br />Info <br />Received Checki# <br />/Cash . <br />Amount <br />Remitted Date Permit/ <br />Service Request # Invoice # Well ID# A <br />V/ ,l'- .-i iCi /24 14 r) LI-1H5 1 <br />SIGNED IL <br />Soil Boring Inspection By Date <br />TYPE OF WORK :553)1CICIV 311S '1)-065g ig2_ EHD 43.06 8/11=19 WELL /PUMP PERMIT