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L WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)4683420 <br /> NON-REFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS <br /> 12911 E Comstock Rd CffY/ZIP Linden Ca 95236 y <br /> -}- <br /> CROSS STREET U��(�'� 1(�5,� .APN Oup��5 PARCEL SIZE J LAND USE APPLICATION# o <br /> M <br /> OWNER NAME Chris Fong PHONE209-610-9375 m <br /> OWNERADDRESS P.O. Box 606 Linden CA 95236 CRY/STATEIZIP Linden 95236 <br /> CONTRACTOR Purviance Drillers, INC PHONE209-887-3554 <br /> CONTRACTOR ADDRESS P-0- BOX 64 Crrr/STATE/ZJPLinden CA 95236 <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTORICONSULTANT ADDRESS CRY/STATE/ZIP <br /> LICENSE R C-57 :.I C-61 C D-09 _Other NUMBER 377923 EXPIRATION DATE 7/3 1/2 1 <br /> BILLING PARTY: :7 OWNER "-'CONTRACTOR C SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING:F General Mineral/Coliform Bacteria(4391):]Dibromochloropropane(4392)u Arsenic(4393) <br /> INTENDED USE j(DomesticfPrivate i-i Irrigation/Agricultural 7 Industrial :1 Water Quality Monitoring G Soil Sampling/Characterization <br /> E Public Water System <br /> M Eifterent from Owner Water System Name Contact Name or Phone Number <br /> TYPE OF WORK D New Well l..Replacement Well C Well Alteration/Modification .'I Other <br /> Monitoring Well(s) #of wells "Soil Boring(s) °ofbO1"9' f,Geotechnical sof borings <br /> 0 Out-Of-Service Well Out-Of-Service Well Renewal :1 Cross-Connection Repair P/� <br /> New Pum C Pum Re lacement X Pum Repair --Raise Well Casing /~ N r <br /> WELL CONSTRUCTION V <br /> Drilling Method Mud Rotary Air Rotary J Auger :_Cable Tool is ;Push Point ' Other eD <br /> Proposed Well Depth ft Excavation in diameter ❑Open Bottom U Gravel Pack/Gravel Size in dyl gtK <br /> Conductor Casing in diameter / Conductor Casing Depth ft �'1(/() 2020 <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched Steel ::Plastic i Stainless Steel ;i Other <br /> Grout Seal Depth ft _]Neat Cement(94 lb bag/5-10 gal water) Sand Cement sack m1 Qj IN <br /> Bentonite(20%solids) �Other /R� C�(fNl <br /> Grout Placement Method Pumped _Free Fall C Other Retardant/Accelerator(name) ARTM L Y <br /> PEDESTAL Installed By Driller C Pump Contractor G Other ENT <br /> i Concrete Pedestal❑Dimensions:Width ft Lengt ft Thick in ❑Christy Box 7 Stove Pipe <br /> PUMP y(Submersible.:Turgine %Other HP Pump Set l �k ft Standing Water Level S 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. <br /> iCE REQIT <br /> SIGNEDA�.f tib ' v�I �/I�(/f-s�.�'.!'�i <br /> TITLE de-ilp GATE <br /> i <br /> r <br /> 'All j <br /> DEPARTMENT US ONLY <br /> Application Accepted By Date Area `+ rr l Employee ID# -/Z <br /> Grout Inspection By Date ❑ SPECIAL Well PelTtllt <br /> Pump Inspection By Date -1 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Permit/ <br /> )Coddles Info <br /> ^ B Cash Remitted Date Service Re u�es)t# Invoice# Well ID# <br /> -I�l ly OJV U. ,I I �/ <br /> EHD 43-O6 817712019 WELL/PUMP PERMIT <br />