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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 />18 . ADVA.NCE NOI1OE REWIRED FOr , 710N5 . c".!L'ASE CALL (20g) n5?-7g,"" <br />SIGNED TM_E Jr-G.44:4, DATE 41/424421 i 1 <br />ki zt, <br />4. <br />fj'y <br />• <br />5 <br />WELLJPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAs-r HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209)468-3420 <br />NON-REFUNDABLE PERMIT Www S ov or /ehd EXPI _ <br />JOB ADDRESS 1 1720 P Eight Mi 1 P Rd CrryizpStockton.ca 95212 <br />CROSS STREET Jacktone Rd APN08914008 PARCEL SIZE 21 . 6 ELAND USE APPLICATION # <br />OWNER NAME VaccarezZa Bros PHONE <br />OWNER ADDRESS 8150 N Duncan Rd crryisTA-remP Li ndpn CA 95736 , <br />CONTRACTOR Purviance Drillers, INC P41ONE209-887-3554 <br />CONTRACTOR ADDRESS P.O. Box 64 c,m5Tmmr2A,Linden CA 95236 <br />SUBCONTRACTOR/CONSULTANT PHONE <br />SUBCONTRACTOPJCONSULTANT ADDRESS CITY/STATE/ZIP <br />LICENSE C-57 = C-61 : 0-09 = Other NUMBER 377923 EXPIRATION DATE 7 /31 /21 <br />BILLING PARTY: : OWNER .. CONTRACTOR L SUBcONTRAcToRICONSULTANT <br />DOMESTIC WELL SAMPLING: r General Mineral/Coliform Bacteria (4391) E. Dibromochloropropane (4392) n Arsenic (4393) <br />INTENDED USE yDomestic/Private : Irrigation/Agricultural ii Industrial LI Water Quality Monitoring i.11 Soil Sampling/Characterization <br />: Public Water System <br />If different from Owner Water System Nurse Contact Name or Phone Number <br />1' TYPE OF WORK 7 New Well r-. Replacement Well : Well Alteration/Modification : Other <br />Monitoring Well(s) # of wells : Soil Boring(s) #01 borings -i] Geotechnical # of borings <br />= Out-Of-Service Well Li Out-Of-Service Well Renewal Li Cross-Connection Repair <br />.: New Pump g Pump Replacement F.7 Pump Repair 71 Raise Well Casing <br />WELL CONSTRUCTION SA N <br />Drilling Method I.. Mud Rotary 7 Air Rotary : Auger : Cable Tool : Push Point i: Other / F <br />4 <br />tv <br />Proposed Well Depth ft Excavation in diameter .1 Open Bottom C..I Gravel Pack/Gravel Size ' ikiria4tr <br />I Conductor Casing in diameter / Conductor Casing Depth it <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched —, Steel t: Plastic tE Stainless Steel A Other <br />Grout Seal Depth ft : Neat Cement (94 lb bag/5-10 gal water) : Sand Cement sack mix/7 gal water <br />_ Bentonite (20% solids) U Other <br />Grout Placement Method Zi Pumped 'i Free Fall [ ] Other Li Retardant / Accelerator (name) <br />PEDESTAL Installed By 1 Driller : Pump Contractor C Other <br />= Concrete Pedestal LDimensions: Width ft Length ft Thick in 11 Christy Box 1 Stove Pipe <br />PUMP X <br /> <br />Submersible:; Turbine 71 Other HP 4 -a-• Pump Set ki,„-, ,'"7-7". ' ft Standing Water Level I .----' S ft <br />DEPARTMENT USE ONLY <br />Area 11 Employee ID# Date 1141 <br />.1 SPECIAL Well Permit <br />:1 WAIVER Received <br />Constructed Well Depth ft <br />PE <br />Codes <br />SC <br />Info <br />Received , ,i,,._ _ Check#/ , Cash <br />Amount <br />Remitted A <br />Date, <br />Permit/ <br />Service Request # Invoice # Well ID# <br />Li3t., 2;0 0' Vi, .)------ -l'i3 ,-f( 1,b1-2-1 1,111704(k/7 1 <br />,-, •t. , <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br /> <br />Date <br />Date 5/ 4P02 <br />Soil Boring Inspection By Date <br />COMMENTS <br />/2_ 2.3-Oset5 <br />#1-40 43-06 6/1112019 <br />WELL /PUMP PERMIT