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DramLinden,CA 95236 <br />PARCEL SIZE Iq) 3 LAND USE APPLICATION # <br />JOB ADDRESs 21014 Comstnrk Rd <br />CROSS STREET Fine Rd APN 09134002 <br />OWNER NAME Kathryn AndprRnn PHONE Tr_ust <br />OWNER ADDRESS P (") Bo x 655 Linden,CA 95236 CITY/STATE/ZIP <br />Purviance Drillers, INC PHONE 209-887-3554 CONTRACTOR <br />CONTRACTOR ADDRESS P.O. Box 64 <br />SUBCONTRACTOR/CONSULTANT <br />SuBcoNTRAcToR/CoNsuLTANT ADDRESS <br />CITY/STATE/ZIPLinden CA 95236 <br />CITY/STATE/Zip <br />PHONE <br />LICENSE x C-57 <br />BILLING PARTY: <br />Other C-61 1 D-09 <br />OWNER CONTRACTOR <br />NUMBER 377923 EXPIRATION DATE 7/31/21 <br />_ SuBcoNTRAcToR/CONsuLTANT <br />Arsenic (4393) DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) D Dibromochloropropane (4392) I <br />INTENDED USE Domestic/Private X Irrigation/Agricultural Industrial Water Quality Monitoring - Soil Sampling/Characterization <br />Public Water System <br />WELL /PUMP PERMIT <br />EHD 43-06 6/11/2019 <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAzELT0N AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />NON-REFUNDABLE PERMIT WWW.Sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED :SS32100V 31IS Water System Name Contact Name or Phone Number If different from Owner: <br /># of wells <br />)e New Well Replacement Well <br />Monitoring Well(s) <br />Out-Of-Service Well <br />New Pump Pump Replacement <br />Other <br /># of borings <br />Well Alteration/Modification <br />Soil Boring(s) <br />s4tdz n1 <br /> < <br />ikkica <br />Out-Of-Service Well Renewal <br />Pump Repair <br /># of borings Geotechnical <br />Cross-Connection Repair <br />Raise Well Casing <br />PEDESTAL <br />ft Thick H in _ Christy Box 1 Stove Pipe <br />Installed ByDriller _ Pump Contractor Other <br />Y Concrete Pedestal _Dimensions: Width 62; ft Length <br />PUMP Submersible - Turbine Other HP Pump Set ft Standing Water Level ft <br />WELL CONSTRUCTION <br />Drilling Method XMud Rotary 0 Air Rotary . Auger - Cable Tool Push Point Other <br />Proposed Well Depth 4 :-- 0 ft Excavation Ii VI., in diameter Xopen Bottom - Gravel Pack/Gravel Size in diameter <br />.4.) kr Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter/4 in Thickness/Gauge/ASTM Sched .,26-1) X Steel Plastic 1-1 Stainless Steel 1 Other <br />Grout Seal Depth ae4V1601. '") ft 0 Neat Cement (94 lb bag/5-10 gal water) XSand Cement ic.), 3 sack mix/7 gal water <br />_ Bentonite (20% solids) 0 Other <br />Grout Placement Method i Pumped 17 Free Fall L Other Retardant / Accelerator (name) <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 />iv 4dalp -;DVAN.CE NOTICE REQUIRED FOR NSF ONS - PLEASE CALL (209) 953-7697 <br />SIGNED aal.011; 144-0-411-C.C, TITLE 4e.-1),' DATE /0 //1/2014 <br />TYPE OF WORK <br />ItYfitt,P.- <br />t itAtt, ottki <br />DEPARTMENT USE ONLY <br />Application Accepted By ---- Date I I/ Area :6,4 C.) q / CI Employee ID# DA <br />Grout Inspection By Agar Date 4-0-----Z0 2{ I SPECIAL Well Permit <br />Pump Inspection By Date ; WAIVER Received <br />Soil Boring Inspection By Date <br />COMMENTS (,g c/ c----—;—?-1-1 -1-ee.C,1 <br />PE <br />Codes <br />SC <br />Info <br />Received <br />By <br />Check#/ <br />Cash <br />Amount <br />Remitted Date Permit/ <br />Service Request # Invoice # Well ID# <br />`13 0 /k() <br />.itri7( <br />\i Sc 4 L 1 ,) Q 440 .70 Y4 P 004-1 g _ <br />_ <br />- <br />N j <br />Q V/ <br />16"44r-), <br />J14 <br />witN, fr-,,CR7.4ZNT <br />Constructed Well Depth ft