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t <br /> c <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 /> 15833 E St Rt 4 Hy Stockton,CA <br /> JOB ADDRESS CITY/ZIP m <br /> CROSS STREET Jack Tone Rd APN 1 8 31 3 0 0 2 PARCEL SIZE v240 LAND USE APPLICATION# O <br /> OWNER NAME Mount Saint Joseph-Saint Elizabeth PHONE m <br /> OWNER ADDRESS - 100 Masonic Ave CITY/STATE/ZIPSanFranclsco, CA <br /> CONTRACTOR Purviance Drillers, INC PHONE209-887-3554 <br /> CONTRACTOR ADDRESS P.O. BOX 64 CITY/STATE/ZIPLi nden CA 95236 <br /> SUBCONTRACTORICONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP <br /> LICENSE X C-57 C-61 D-09 Other NUMBER 377923 EXPIRATION DATE 7/31 /21 <br /> BILLING PARTY: 7 OWNER CONTRACTOR SU13CONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING:C General Mineral/Coliform Bacteria (4391)�3 Dibromochloropropane(4392)l Arsenic(4393) <br /> INTENDED USE Domestic/Private Jr Irrigation/Agricultural Industrial ❑ Water Quality Monitoring Soil Sampling/Characterization <br /> _ Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK a(New Well Replacement Well Well Alteration/Modification Other <br /> - Monitoring Well(s) #of wells Soil Boring(s) #of borings Geotechnical #of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method>(Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depth (o5a ft Excavation /9 X11- in diameter )(Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter 14op in Thickness/Gauge/ASTM Sched e 25-6 X Steel Plastic Stainless Steel i Other <br /> Grout Seal Depth fd(*) ft I Neat Cement(94 Ib bag/5-10 gal water) XSand Cement 1O- ,3 sack mix/7 gal water <br /> Bentonite(20%solids) _j Other <br /> Grout Placement Method Pumped Free Fall i: Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor I- Other <br /> Concrete Pe estal Dimensions:Width ft Length eC ft Thick in Christy Box Stove Pipe <br /> PUMP Submersible . Turbine Other HP Pump Set ft 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 LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. f_ I <br /> NOTICE REQU •4)R INS f:7CTIONS T _.... <br /> SIGNED'-, TITLE Corporate Secretary DATE 1 1 /2/2020 <br /> 1 <br /> lT F r <br /> DEPARTMENT USE ONLY b1�NT <br /> Application Accepted By Z_ Date d42 J Area �/�/ Employee ID# <br /> Grout Inspection By Cllk_� Date I SPECIAL Well Permit <br /> Pump Inspection By Date 7WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received he Amount Permit/ <br /> Codes Info B Cas Date Remitted Service Re uest# Invoice# Well ID# <br /> EHD 4306 6/11/2019 WELL/PUMP PERMIT <br />