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WELL/PUMP PERMIT <br />SAN JOACIUN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAsT HAZELTON AVENUE - STOCKTON CA 95205-6232 (209) 468-3420 <br />NON-REFUNDABLE PERMIT WwW.Sigov.orgiehd EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 14171 E Eight Mile T? CITY/ZIP Li nden , C'A q 9 ? 3 6 <br />cRosssrass-r Jacktone Rr3 APN 065 0701 7 PARCEL SIZE) '41) LAND USE APPLICATION # <br />OWNER NAME Ra n dy r n a PHONE <br />OWNER ADDRESS 14171 E Eight Mile Rd <br />CONTRACTOR Purviance Drillers, INC <br />CITY/STATE/ZIP Linden , CA 55236 <br />PHONE 209-887-3554 <br />CONTRACTOR ADDRESS P.O. Box 64 CITY/STATE/ZIP Linden CA 95236 <br />SUBCONTRACTOR/CONSULTANT <br /> <br />PHONE <br /> <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br /> <br />CITE/STATE/ZIP <br /> <br />LICENSE C-57 _ C-61 C D-09 7, Other NUMBER 377923 ExPIRATION DATE 7/31 / 21 <br />BILLING PARTY: OWNER El CONTRACTOR L. SUBCONTRACTOR/CONSULTANT <br />It Thick = Christy Box Li Stove Pipe <br />PEDESTAL Installed By 2 Driller C Pump Contractor C Other <br />Concrete Pedestal :Dimensions: Width ft Length <br />PUMP HP .4- *Submersible:: Turbine C Other Pump Set \t\'-- ft Standing Water Level \ .-2 1 ft <br />TYPE OF WORK New Well C Replacement Well -= Well Alteration/Modification = Other <br />l= Monitoring Well(s) # of wells 2 Soil Boring(s) # ofborIngs 2 Gedechnical #01 borings <br />Out-Of-Service Well = Out-Of-Service Well Renewal 2 Cross-Connection Repair <br />= New Pump ::: Pump Replacement 'Pump Repair — Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method : Mud Rotary r: Air Rotary i.i Auger 2 Cable Tool = Push Point il Other <br /> <br />Proposed Well Depth ft Excavation in diameter El Open Bottom II Gravel Pack/Gravel Size <br /> <br />= Conductor Casing in diameter 1 Conductor Casing Depth ft <br />Well Casing Diameter In Thickness/Gauge/ASTM Sched 1 Steel = Plastic I= Stainless Steel "I Other <br /> <br />Grout Seal Depth ft = Neat Cement (94 lb bag/5-10 gal water) . I Sand Cement <br />LI Bentonite (20% solids) Li Other <br />Grout Placement Method 7 Pumped 0 Free Fall 1_ Other C Retardant / Accelerator (name) <br />in diameter <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 COMPENSAT • WS. <br />.TNANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-76V <br />SIGNED r ,A TITLE (.) I in) srs DATE <br />sack mix/7 gal water <br /> <br />INTENDED USE XDomestic/Private El Irrigation/Agricultural (I Industrial 0 Water Quality Monitoring C Soil Sampling/Characterization <br />= Public Water System <br />S different from Owner Water System Name Contact Name or Phone Number <br />DOMESTIC WELL SAMPLING: n General Mineral/Coliform Bacteria (4391) LI Dibromochloropropane (4392) 0 Arsenic (4393) SS3)JOGIV 311S Ell <br />IMINE NM 111.1111 _, I • UM A. - IMEEMIIIIMEM II IIIEI IIEMIERmilla- <br />MiliiIIMMEN <br />IV <br />MIIIIIMMEMIIMMIIIIMIEMMI EINEMMEELVEZMIIIINMEMII <br />ElEIMMENIIIIIM <br />MIME <br />MEE <br />MESE NMI <br />MI c, • M MIME MEM MINIM 111111111111IMENI MIMI INEMEEM11111111 11•EN MMEMIIII EENEMMIIIIIII IIIIIIIII MEM= 1111miNimigEillia MEM • 11EIRM.51 Mahl MEMIM 11• MEM= • II. EM morn MEI EN MOM EMT. • EMEIEMI MN <br />. NT <br />WED <br />0 2020 <br />DEPARTMENT USE ONLY <br /> <br />Application Accepted By Date Z--- Date OPFA,A) <br /> <br />Grout Inspection By Date <br /> <br />Pump Inspection By Date 5/11—P.024 <br /> <br />Soil Boring Inspection By Data <br />COMMENTS <br />PE <br />Codes <br />SC <br />Info <br />Received Check*/ <br />Cash <br />Amount <br />Remitted Date Permit/ <br />Service Request # Invo i ce # Well ID# <br />i-eed -t3 0 S (7 // V :, C. 1;7 7 tl) 1-U7 i-P-0 0 Li IGUA— <br />c. 11 II --: - <br />_...... _...__._ <br />WELL /PUMP PERMIT <br />IN COUNTY <br />ENVIRONMENTAL <br />Area 11 /6/67 EmployeeID# <br />_H T DEPARTMENT <br />:1 SPECIAL Well Permit <br />El WAIVER Received <br />Constructed Well Depth ft