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PUMP <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 THCALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LA <br />1 •Submersible: Turbine Li Other HP '-}"' Pump Set ri 0 ft Standing Water Level ft <br />Date <br />Date <br />ate <br />Date <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.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADORE! cr.-wintry Rd <br />crrawStockton, CA 95215 <br />CROSS STREET (LRhJflEu R d <br />APNJ 8514056 <br />PARCEL SIZE 1 -9 I LAND USE APPLICATION # <br />OWNER NAME Larry Cox <br />PHONE <br />OWNER ADDRESS Al -19 colintry crryis-rxrEOPS tock t on CA 95219 <br />CONTRACTOR Purviance Drillers, INC <br />PHONE 209-887-3554 <br />CONTRACTOR ADDRESS P - 0 • Box 64 crrasTATEizipL nd en CA 95236 <br />SUBCONTRACTOR/CONSULTANT <br />PHONE <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />CITY/STATE/21P <br />LICENSE x C-57 2. C-61 0-09 I Other NUMBER 377923 EXPIRATION DATE 7/31/21 <br />BILLING PARTY: <br />OWNER <br />CONTRACTOR U SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: 13 General MineraUColiform Bacteria (4391) D Dibromochloropropane (4392) ri Arsenic (4393) <br />?Domestic/Private Li lnigation/Agricultural '7 Industrial 7 Water Quality Monitoring ii Soil Sampling/Characterization <br />_ Public Water System <br />If different from Owner. <br />TYPE OF WORK 7 New Well r; Replacement Well ; Well Alteration/Modification Other <br />WELL CONSTRUCTION <br />2. New Pump -pump Replacement i_. Pump Repair : Raise Well Casing <br />..-: Monitoring Well(s) # of wells '1 Soil Boring(s) # of borings <br />'.1 Out-Or-Service Well Li Out-Of-Service Well Renewal Cross-Connection Repair <br />Z.: Geotechnical Rot borings <br />Drilling Method : Mud Rotary t-, Air Rotary .; Auger r.:. Cable Tool : Push Point 1] Other <br />INTENDED USE <br />Water System Name Contact Name or Phone Number :SSRICICIV 31IS Proposed Well Depth ft Excavation in diameter ii Open Bottom D. 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 13 Steel ::: Plastic 1--, Stainless Steel i'l Other <br />Grout Seal Depth ft i: Neat Cement (94 lb bag/5-10 gal water) 7, Sand Cement sack mix/7 gal water <br />L. Bentonite (20% solids) D Other <br />Grout Placement Method _ Pumped ; Free Fall E Other ' Retardant / Accelerator (name) <br />PEDESTAL Installed By 1. Driller ; Pump Contractor t.= Other <br />I Concrete Pedestal :Dimensions: Width ft Length ft Thick <br />in :1 Christy Box 11 Stove Pipe <br />l'i•E NOTICE P73UIRIF [---'T.T-m -77.7...ASE CALL, (27•P:' <br />SIGNEL A.k Tm.E Cc. DATE 5RA <br />tv -r <br />:rr‘ ''N6* <br />Q.a,‘ ,S•4, <br />DEPARTMENT USE ONLY <br />Application Accepted By <br /> <br />Grout Inspection By <br />Pump Inspection B <br /> <br />Soil Boring Inspection By <br />COMMENTS <br />Area LI/ Employee ID# <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />PE <br />Codes <br />SC <br />Info <br />Received Check/# <br />iCash <br />Amount <br />Remitted L Date Permit/ <br />Service Request # Invoice # Well ID# <br />Li -1 V i 0 0 iig2— ifi W--- 4 -77 (212011-L W9011611-OSS <br />- / ,L 1 <br />.-/2S7O75/ WELL /PUMP PERMIT