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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />NU11-Mtt-UNUAI3Lt PERMIT <br />JOB ADDRESS 5841 E St Rt <br />CROSS STREETAvalon Dr <br />OWNER NAME DiLeo Family <br />www.sigov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />26 Hy CITY/ZIP Stockton, CA <br />APN 10123020 PARCEL SIZE 18 _8 LAND USE APPLICATION # <br />Partnership PHONE 59-281 -4587 <br />OWNERADDRESS 201 7 W Bullard #148 CITY/STATE/zip Fresno, CA 9371 1 <br />CONTRACTOR Purviance Drillers, INC PHONE209-887-3554 <br />CONTRACTOR ADDRESS P - 0 . BOX 64 CITYISTATE/ZIPL i nd e n CA 95236 <br />SUBCONTRACTOR/CONSULTANT <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />LICENSE X C-57 <br />BILLING PARTY: <br />C-61 D-09 <br />❑ OWNER <br />Other <br />CONTRACTOR <br />CITY/STATE/ZIP <br />NUMBER 377923 <br />_ SUBCONTRACTOR/CONSULTANT <br />PHONE <br />EXPIRATION DATE 7 / 31 / 21 <br />DOMESTIC WELL SAMPLING: f; General Mineral/Coliform Bacteria (4391) [1 Dibromochloropropane (4392) I ' Arsenic (4393) <br />INTENDED USE Domestic/Private X 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 7,New Well Replacement Well Well Alteration/Modification Other <br />SC Received <br />Info B <br />Monitoring Well(s) # of wells Soil Boring # of borings s) Geotechnical <br />o r, <br />�B <br />Out -Of -Service Well Out -Of -Service Well Renewal u Cross -Connection Repair <br />New Pump Pump Replacement Pump Repair ❑ Raise Well Casing <br />C`��°r�4 <br />WELL CONSTRUCTION <br />9 <br />Drilling Method Z( Mud Rotary Air Rotary Auger Cable Tool Push Point Other SAN <br />JO ! P021 <br />Proposed Well Depth 4 26 ft Excavation ZZ in diameter l Open Bottom 1 Gravel Pack/Gfavlll�$ <br />/%N�NCO& ameter <br />Conductor / <br />d:S�asing Depth ft <br />Fpy� <br />WellCasing Diameter/2ameter <br />e ASTM ScheConductor <br />g 9 1( Steel Plastic Stainless Steel <br />Other NT <br />Grout Seal Depth .ZOO (+/—) ft Neat Cement (94 Ib bag/5-10 gal water) X Sand Cement 10.3 <br />sack mix/7 gal water <br />Bentonite (20% solids) _ Other <br />Grout Placement Method X Pumped Free Fall i Other _ Retardant / Accelerator (name) <br />PEDESTAL Installed By )_C Driller _ Pump Contractor L Other <br />X Concrete Pedestal Dimensions: Width 5 ca ft Length 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. <br />`� ".a.r Yo'.itl:sd. IY6�' 1 CCsL tiCvaLfitte:LJ' T't�aG FYJJ`L"v f ILiYV� - �"`i_L�1.aC; l:�►L.L (et i. <br />SIGNED �`21� fes' �a'eie";LIV'C4i TITLE Corporate Secretary DATE 5/10/21 <br />E ARTMENT USE ONLY <br />Application Accepted B Date <br />Grout Inspection By s US t.C.lf r Date <br />Pump Inspection By Date <br />Area__L ! Employee ID# <br />❑ SPECIAL Well Permit <br />D WAIVER Received <br />Soil Boring Inspection By Date Constructe Well De/pth ft <br />COMMENTS 6��'L t ;� �ncL ter IZ(--1k:-w r ST '1-y'L-c � �Ll'1 �l �t tG� �✓C'v �llL't. <br />.r� <br />PE <br />Codes <br />SC Received <br />Info B <br />as <br />Amount D to <br />Remitted <br />Permit/Invoice <br />Service Request # <br /># Well ID# <br />t <br />) J <br />tHU 43-06 6111!2019 WELL /PUMP PERMIT <br />