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3Z i- 6,62" 7th <br />- .1.At1112 <br />WELUPUMP PERMIT '..r^,) <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1668 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 466-3420 <br />NON -REFUND LE PERMIT www.sigov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS Devries Rd Cf yizp Lodi CA 95242 <br />073 Zo <br />CROSS STREET Peltier Rd ��V�APIJ�I/ PARCEL SIZE LAND USE APPLICATION,#( <br />OWNERNAME vv�s F-QWrc�'-er& ri ret z;4,,V �'� �/rj Z�o p� PHONEZ5;7-- -ydl j//rL <br />O <br />OWNERADDREss 213?$ D,-vries Rd CmISTATE21PLodi,CA 95242 <br />CONTRACTOR Purviance Drillers, INC P14ONE 2 0 9 - 8 6 7 - 3 5 5 4 <br />CONTRACTOR ADDRESS P.O. Box 64 CrTYISTATE2IPL i nd en CA 95236 <br />SUBCONTRACTORICONSULTANT PHONE <br />SUBCONTRACTOR/CONSULTANT ADDRESS CrrY/STATEILP <br />LICENSE k C-57 _ C-61 D-09 Other NUMBER 377923 EXPIRATION DATE 7/ 31 / 21 <br />BILLING PARTY: Li OWNER C CONTRACTOR Li SUBCONTRACTORICONSULTANT <br />DOMESTIC WELL SAMPLING: L: General i rai/Coliform Bacteria (4391) [; Dibromochloropropane (4392) 0 Arsenic (4393) <br />INTENDED USE omesbc/Private k friigkordAgricultural a Industrial Water Quality Monitoring C Soil Sampling/Characterization <br />Public Water Sys%m- <br />tf different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK New Well Replacement Well Well Alteration/Modification ❑ Other <br />Monitoring Wallis) #of wells Soil Boring (s) #Ofbodn9s Geotechnical 9ofbadngs <br />Out -Of -Service Well Out -Of -Service Weil Renewal a Cross -Connection Repair <br />7 New Pump Pumn RPnlarAmant -�e Pi imn Rannlr ,r,_0 _.. r... - Rolca tnfeu rr-- C%. <br />Drilling Method Mud Rotary 7 Air Rotary :_ Auger :: Cable Toot -] Push Point rl Other N 1,v <br />Proposed Well Depthft Excavation in diameter :I Open Bottom FJ, Gravel Pack/Gravel Size in diamete <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter_ in Thickness/Gauge/ASTM Sched : Steel El Plastic Stainless Steel i Other <br />Grout Seal Depth ft J Neat Cement (94 lb bag/5-10 gal water) LI Sand Cementsack.W7 gal water <br />Bentonfte (20% solids) J Other <br />Grout Placement Method _: Pumped -, Free Fall L Other ,: Retardant / Accelerator (name) <br />PEDESTAL Installed By L Driller L Pump Contractor L Other <br />Concrete Pedestal (]Dimensions: Width ft Length ft Thick in ❑ Christy Box ] Stove Pipe <br />PUMP ubmersible-: Turbine Other HP 1 Pump Set---L,�- it Standing Water Level ft <br />I HEREBY CER IFY 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 />ADVANCENOTICE REQUIR—En FOR INaSPE/ C-T!OhLR - Pf caaE- ret I Ma► "- a-7rir?7 <br />SIGNED \ / TITLE DATE "5-& <br />//DEPARTMENT USE ONLY r I <br />Application Accepted By � L C' Date S 4 Area Ll % �q Employee ID# INA <br />Grout Inspection By 4 4 Data 11 SPECIAL Well Permit <br />Pump Inspection By Date 5��2n Fl WAIVER Received <br />Soil Boring In��`ction By Date Cc strutted 1N�11 Dqq - n <br />COMMENTS 7 1A� ` r 'r% b �� ✓ll//� /de��_]�tt=1Y/ <br />PE I <br />Codes <br />SC I Received Check#/ <br />Info Cash <br />Amount Date PerrtlW Invoice # Well ID# <br />Remitted I 'AmBR9 est# <br />FMD43-06 6/11r2079 <br />WELL (PUMP PERMR <br />RTngt <br />