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0 <br />WELUPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 -6232 (209) 468-3420 <br />N-KEFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUEC <br />ADDRESS 11277 N St Rt Hwy 99 Frontage Rd CITY/ZipLodi,CA 95240 <br />SSSTREET E Morse Rd APN05914014 PARCEL SIZE <br />1 ++ 11 t I .2�4_LAND USE APPLICATION <br />tl#✓ G1�-5� 22 � J <br />ER NAME Jo s__Womb l e -� IL Of? 1�(1a L�c., (,If. PHONE (''••Yt1-G,e <br />IERADDRESS 11277 N St Rt Hwy 99 Frontage rd CITY/STATE/ZIPLodi. CA 95240 <br />TRACTOR Purviance Drillers, INC PHONE209-887-3554 <br />TRACTORADDRESSP-0- Box 64 CITY/STATE21PLiride n CA 95236 <br />LTANT <br />TAINT ADDRESS <br />LICENSE X C-57 C-61 - D-09 <br />BILLING PARTY: _ OWNER <br />CITYISTATE/ZIP <br />Othef NUMBER 377923 <br />CONTRACTOR SUBCONTRACTORICONSULTANT <br />PHONE <br />EXPIRATION DATE 7/31 /23 <br />DOMESTIC WELL SAMPLING: F General Mineral/Coliform Bacteria (4391) -; Dibromochloropropane (4392) C Arsenic (4393) <br />INTENDED USE omeviGPrivale �] Irrigation/Agricultural . Industrial -: Water Quality Monitoring Soil Sampling/Characterization <br />C Public Water System <br />If different from Owner Water System Name Contact Name or Phone Number <br />TYPE OF WORN G New Well I- Replacement Well u Well AlteraUoNModification I- Other <br />C Monitoring Well(s) # of wells D Soil Boring(s) "borings ❑ Geotechnical a of beings <br />D Out -Of -Service Well G Out -Of -Service Well Renewal D Cross -Connection Repair A <br />- New Pump (Pump Replacement 7 Pump Repair C Raise Well Casino <br />JO <br />Drilling Method '- Mud Rotary Air Rotary Auger Cable Tool - Push Point Other E <br />Proposed Well Depth ft Excavation in diameter Open Bottom -, Gravel Pack/Gravel Size <br />7 -Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched Steel - Plastic _ Stainless Steel Other <br />Grout Seat Depth ft -: Neat Cement (94)b bag/5-10 gal water) Sand Cement sack mix/7 gal water <br />- Bentonite (20% solids) -i Other <br />Grout Placement Method - Pumped = Free Fall C Other Retardant I Accelerator (name) <br />PEDESTAL Installed By Driller - Pump Contractor Other <br />Concrete Pedestal _:Dimensions: Width ft Length ft Thick in - Christy Box r Stove Pipe <br />LPuMP `�uhmersihle Turbine - Other HP %- Pump Set R 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. 1 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 At I <br />DEPARTMENT I)SE ONLY <br />Application Accepted By �Z- Date 1/h / Area Employee ID# NA <br />Grout Inspection By _ Date / I SPECIAL Well Permit <br />Pump Inspection By'`~ Date ® D WAIVER Received <br />Soil Boring Inspection By _ Date Constructed Well Depth ft <br />COMMENTS <br />O <br />m <br />N <br />EENT <br />l �F6 <br />I�4?021 <br />?UlN C <br />41ENO LINT y <br />ARTMENT <br />PE <br />Codes <br />SC Received Check#/ Amount Date PermiU Invoice # Well ID# <br />Info B Cash Remitted / Service Request# <br />EHC 43-Ofi 6!118019y /J r - /✓i/ 5p,, 0 0 WELL!PUMP PERMIT <br />