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PAY r <br />REC, <br />SUN <br />SA ENS R <br />HEALTH <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-342C <br />NUN-KEFUNDABLE PERMIT WWW sjgov Or lehd EXPIRES 1 YEAR FROM DATE ISSUED <br />JOBADDRESS 20149 N Clements Rd G} Cm,/zfPLo�jdi CA 95240 <br />CROSS STREET Stampede Rd APN / `� PARCEL SIZE (I0V LAND USE APPLICATION# <br />OWNER NAME Steve Smit PHONE209-642-9919 <br />OWNERADDRESS20149 N Clements Rd CITY/STATE/ZIpLodi Ca 95240 <br />CONTRACTOR Purviance Drillers, INC <br />CONTRACTOR ADDRESS P.O. BOX 64 <br />SUBCONTRACTORICONSULTANT <br />SUBCONTRACTORICONSULTANT ADDRESS <br />LICENSE lll� C-57 ] C-61 D-09 <br />BILLING PARTY: : � OWNER <br />PHONE209-887-3554 <br />Cm/STATE/ZIPLinden CA 95236 <br />PHONE <br />CITY/STATE21P <br />❑ Other NUMBER J '7c' 22 EXPIRATION <br />Ci CONTRACTOR 1' SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: t-: General MinerallColiform Bacteria (4391) C Dibromochloropropane (4392) G Arsenic (4393) <br />NTENDED USE p Domestic(Pdvate G Irrigation/Agricultural C Industrial E Water Quality Monitoring D Soil Sampling/Characterization <br />C Public Water System _ <br />If different from Owner Water System Name Contact Name or Phone Number <br />-. iv— -ou , muplacemem vvell J vvell AlteratlONMoamcation : Other <br />^_ Monitoring Well(s) of wells C Soil Boring(s) #of borings ❑Geotechnical if of borings <br />Out -Of -Service Well ❑ Out -Of -Service Well Renewal ,' Cross -Connection Repair <br />New Pump 4 Pump Replacement 0 Pump Repair ❑ Raise Well Ca -,;inn <br />Drilling Method __- Mud Rotary ❑ Air Rotary it Auger C Cable Tool Push Point D Other <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel PacklGravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched—_ Steel fl Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth ft —,Neat Cement (941b bagl5-10 ga/ water} , Sand Cement Sack mix/7 gal water <br />0 Bentonite (20% solids) ❑ Other <br />Grout Placement Method ¢ Pumped _ Free Fall C; Other Retardant / Accelerator (name) <br />PEDESTAL Installed By G Driller C Pump Contractor , Other <br />Concrete Pedestal ,Dimensions: Width ft Length It Thick in C Christy Box G Stove Pipe <br />PUMP IO Submersible, Turbine ❑ Other HP Pump Set 0 ft Standing Water I I! 1 tt <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPUCATION 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 cnMDI IANcc U rru wl I <br />UtPARTMENT USE, ONLY <br />Application Accepted By �' Date (_4z Z f7G J Area 7 /' 41 Employee ID# A <br />Grout Inspection By _ 9 Date ❑ SPECIAL Well Permit <br />Pump Inspection By i r.,.vt S(c (SG.,Y_, rc. Y Data �t''Z� DELI ❑ WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />N <br />m <br />D <br />M <br />H <br />PE <br />Codes <br />SC Received <br />Info FAZICash <br />Check#/ Amount permit/ <br />Remitted Date rvice Re # Invoice # Well ID# <br />1G I <br />O� <br />SGS 1 r <br />i t <br />FHn n't.nc ci„m,n <br />A 11 <br />WELL !PUMP PERMIT <br />