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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 />PERMIT <br />FROM DATE ISSUED <br />JOB ADDRESI -' Mar-kvi 1 1 e Rd CITY/ZIP Clements . CA <br />CROSSSTREETr�r)ynt-P Crank T.n APN n0908fl(1R PARCEL SIM 1jLAND USE APPLICATION# <br />OWNERNAME Watts Vineyard PHONE <br />OWNER ADDRESS 1 051 T,i nr of n AVP CITY/STATEMP Lodi , CA 95240 <br />CONTRACTOR Purviance Drillers, INC PHONE209-887-3554 <br />CONTRACTOR ADDRESS P.O. Box 64 Cm./STATERIPLlnden CA 95236 <br />SUBCONTRACTORICONSULTANT <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />LICENSE R C-57 <br />BILuNO PARTY: <br />PHONE <br />CITY/STATEZP <br />C-61 D-09 Other NUMBER 377923 EXPIRATION DATE 7/ 31 / 21 <br />OWNER 71 CONTRACTOR SUBCONTRACTORICONSULTANT <br />DOMEsTIc WELL SAMPLING: C General Mineral/Coflform Bacteria (4391) C Dibromochloropropane (4392) [; Arsenic (4393) <br />INTENDED USE Domestic/Private Xlrrigation/Agriculturel _ Industrial D Water Quality Monitoring C Soil Sampling/Characterization <br />Public Water System <br />If different from Owner Water System Name Contact Name or Phone Number <br />TYPE OF WORK = New Well . Replacement Well C Well Alteration/Modification C Other JAY�jF� <br /># <br />Monitoring Well ❑ <br />Wallis) # of wells Soil Boring(s) of borings :1 Geotechnical # ofborings / <br />Out -Of -Service Well <br />Out -Of -Service Well Renewal L' Cross -Connection Repair ve <br />J New Pump 1-4', PUmD Replacement _7 PUMD Repair C Raise Well Casino LJ <br />Drilling Method .1 Mud Rotary [: Air Rotary ❑ Auger ❑ Cable Tool a Push Point U Other <br />Proposed Well Depth ft Excavation in diameter t l Open Bottom n Gravel Pack/Gravel Size in c IV <br />Conductor Casing in diameter / Conductor Casing Depth <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Schad , Steel ❑ Plastic 1 Stainless Steel ❑ Other <br />Grout Seal Depth ft Neat Cement (94 lb bag/S10 gal water) C Sand Cement $a t ml*77 ilk wee <br />Bentonite (20% solids) C Other <br />Grout Placement Method Pumped :5 Free Fall C Other ;: Retardant I Accelerator (name) <br />PEDESTAL Installed By Driller C Pump Contractor C Other <br />Concrete Pedestal Dimensions: Width It Length ft Thick in ❑ Christy Box C Stove Pipe <br />rPUMP _. Submersibley(,Turbine C� Other HP_ Pump Set��� ft Standing Water Level a/o ft <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 />MIMM 48 140 1 DdANC.E N0T10E REQ +P!�r FOP�!NSPE TIONS - PLEASE CAI_ f2na� <br />'41 <br />SIGNED <br />.SIGNED TITLE 4 ' DATE <br />1�1 <br />DEPARTMENT USE ONLY <br />Application Accepted By L Date <br />Grout Inspeclion By Date <br />Pump Inspection By ;,n i. -i 0 Date 4(1.1 �y�; -s-c_ �%v..'Z <br />Area Employee ID# <br />'_l SPECIAL Well Permit <br />❑ WAIVER Received <br />Soil Boring Inspection By Date _ Constructed Well Depth ft <br />COMMENTS Mor -M Of 17SSY' i %>t /' L7(?q0C)13 <br />PESC Received Check#/ Amount at <br />Codes Info Cash Remitted a <br />Permit/ Invoice # Well IDN <br />Service Request # <br />l <br />EHD 4306 8/112019 � /� / _. <br />,_�/�ff_'��/L• / � -r �y�/�.rf� WELL !PUMP PERMIT <br />08 2021 <br />'AR rALry <br />T/Oe)V7. <br />