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r , <br /> WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAzELTON AvENuE-STOCKTON CA 95205-6232(209)4684420 <br /> NON-REFUNDABLE PERMIT -www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 2257 Lucile Ave TcrnmPStockton,CA 95209 In <br /> In <br /> CROSS STREET DOR Ave APN 08020007 PARCEL SIZE.91 LAND USE APPLICATION# p <br /> (y� X <br /> OWNERNAME Linda Smith PHONE ���•��_ r-1/L y <br /> OWNER ADDRESS 7257 Lucile Ave Crry1STATE0P_atQckton.CA 95209 <br /> COTITRACTOR Purviance Drillers, INC PHoNE209-887-3554 <br /> CONTRACTOR ADDRESS P-0. Box 64 CrrrISTATEMpL i nden CA 95236 <br /> SUBCONTRACTORICONSULTANT PHONE <br /> SU13CONTRACTORICONSULTANT ADDRESS CIYISTATEIZIP <br /> LICENSE R C-57 ['C-61 ❑D-09 n Other NUMBER 377923 EXPIRATION DATE 7/31/21 <br /> BILLING PARTY: TOWNER CONTRACTOR ❑ SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:[:General Mineral/Coliform Bacteria(4391)❑Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE Domestic/Prtvate :i Irrigation/Agricultural G'Industrial Water Quality Monitoring a Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner. Water System Name Contact Name w Phone Number <br /> TYPE OF WORK _:New Well Il Replacement Well :Well Alteration/Modification n Other <br /> 7 Monitoring Well(s) #of wells _]Soil Boring(s) of borings D Geotechnical of borings <br /> I Out-Of-Service Well L'Out-Mervice Well Renewal ❑Cross-Connection Repair <br /> New Pum t G Pum Repair 2 Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary [I Air Rotary . Auger Cable Tool Push Point ❑ Other <br /> Proposed Well Depth it Excavation in diameter ❑Open Bottom M Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched Steel C Plastic n Stainless Steel ri Other <br /> Grout Seal Depth ft -1 Neat Cement(94 lb bagl5-10 gat water) ❑Sand Cement .lack mixl7 gal water <br /> Bentonite(20%solids) ❑Other <br /> Grout Placement Method Pumped _Free Fall [I Other C Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller . Pump Contractor C Other <br /> 'J Concrete Pedestal CDimenslons:Width ft Length ft Thick in C Christy Box i,Stove Pipe <br /> PUMP Submersibles Turbine Other HP Pump set -6L� _ft Standing Water Level ft <br /> 1 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 THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> SIGNED TITLE <br /> DATE � Z� <br /> 1 1 -77771 <br /> S <br /> E�MENT <br /> El QED <br /> 1 ?021 <br /> Qultv C <br /> tut, Fp ENOU NTY <br /> DEPARTMENT USE ONLY ARTME/vT <br /> Application Accepted By � Date 1 %iJr Area y � Employee ID# I'l <br /> Grout Inspection By Date 0 SPECIAL Well Permit <br /> Pump Inspection By rel 5 �/y r✓. Date ❑ WAIVER Received <br /> Soil Baring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Permit/ <br /> Codes Info B Cash Remitted Date Service Re uest# Invoice# Well ID# <br /> EHD 43-O6 6/17/4079 WELL]PUMP PERMIT <br />