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INTENDED USE XCOMestiC/Private E Irrigation/Agricultural L: Industrial ":3 Water Quality Monitoring Li Soil Sampling/Characterization <br />Public Water System <br />dtfferent from Owner Water System Name Contact Name or Phone Number <br />-•= <br />Application Accepted By <br /> <br />Grout Inspection By <br /> <br />Pump Inspection By <br /> <br />Soil Boring Inspection By <br />COMMENTS <br /> Date elb 6//). Area Lijrn <br />DEPARTMENT USE ONLY <br />Employee ID# DA <br />Date /V tiP_,024 <br />Date <br />71 WAIVER Received <br />Constructed Well Depth ft <br />Date 1 SPECIAL Well Permit <br />e- • • <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCICION CA 93205 -6232 (209) 468-3420 <br />NON-REFUNDABLE PERMIT wwW.S • ov.or iehd EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 6333 E. Eight Mile Rd <br />crrymp Stockton, CA 95215 <br /> co <br />CROSS STREET Chantel Ln ApN 06303020 PARCEL SIZE7 • 58 LAND USE APPUCATION # <br />ovaiEnNAmE Carla Moznett <br />PHONE <br />OWNER ADDRESS 6333 E. Eight Mile Rd Cri-r/STAYEIZip t o ckt on , CA 95215 <br />CONTRACTOR Purviance Drillers, INC Pe0NE 20 9 -687-3554 <br />CONTRACTOR ADDRESS P • 0. Box 64 cmdfir„mpLinden CA 95236 <br />SUBCONTRACTOR/CONSULTANT PHONE <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />CITY1STATEMP <br />LICENSE x C-57 I C-61 I? 0-09 ii Other NUMBER 377923 EXPIRATION DATE 7 /3 1 /2 1 <br />BILUNG PARTY: L". OWNER 2 CONTRACTOR .3 SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: I; General Mineral/Coliform Bacteria (4391) DibromochlOrOpropane (4392) n Arsenic (4393) <br />TYPE OF WORK I New Well F: Replacement Well 7 Well Alteration/Modification 7. Other <br /> <br />": Monitoring Well(s) # of wells ": Soil Boring(s) tt of borings <br /> <br />Out-Of-Service Well L"' Out-Of-Service Well Renewal <br />"1 New Pump 7 Pump Replacement XPump Repair <br />WELL CONSTRUCTION <br />Drilling Method '" Mud Rotary 7 Air Rotary "i Auger 7 Cable Tool ;; Push Point I' Other <br />Proposed Well Depth ft Excavation in diameter "1 Open Bottom <br /> <br />Conductor Casing in diameter / Conductor Casing Depth <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched "". Steel <br />Grout Seal Depth ft I Neat Cement (94 lb bag/5-10 gal water) <br />_ Bentonite (20% solids) 0 Other <br />/VA y 0 <br />Geotechnical <br />;j Cross-Connection Repair <br />E, Raise Well Casing <br />Li Gravel Pack/Gravel Size _4t_Adiameter <br />otitgAeN QUI <br />ft <br />Plastic "I Stainless Steel .1 rk ONi <br />Sand Cement sack mid? <br />Grout Placement Method 2. Pumped D Free Fall t] Other I Retardant / Accelerator (name) <br />PEDESTAL Installed By 1.2 Driller Pump Contractor C Other <br />_ Concrete Pedestal "iDimensions: Width ft Length ft Thick in ;3 Christy Box 0 Stove Pipe <br /> <br />Pump Set .\ It Standing Water Level ft <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 UCENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS, <br />'VANCE NOTICE R77127,P7 7 FC,7 IMS7-7"-T S r?'' 7-7b•nr--.7çAr <br />SIGNED c?ete-A-e6i2P144-z-t."--Ae....;. TITLE DATE 41/3 11/4 17' <br />Zr. <br />1202.. 'XSubmersible I: Turbine Li Other HP <br />PE <br />Codes <br />SC <br />Info <br />Received <br />(dAr_ <br />Check#/ Amount <br />Remitted Date <br />- <br />Permit/ <br />ies_vIce R wit # , Invoice* Well ID# <br />1.4;hc.,.._ 4 7] , 1' 1 V F01) (1110 <br />... <br />. a2-Pfly-a3/ <br /> WEU_ /PUMP PERMIT