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WELUPUMP PERMIT <br />t SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 7868 EAST HAzELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />NUI I-KEFUNUABLE PERMIT WWW.Sjgoy.Orglehd EXPIRES 1 YEAR FROM DATE ISSUED <br />JOBApDREss 24848 N St Rt Hwy 88 CITv21P Clements,CA 95227 <br />CROSS STREET Collier Rd APN 0 21 1 8 0 0 8 PARCEL SIZE2 9 --4 4 LAND USE APPLICATION # <br />OWNER NAME Richard Dias PHONE <br />OWNER ADDRESS 24848 N St Rt Hwy 88 CrrY/STATE/ZIP Clements,CA 95227 <br />CONTRACTOR Purviance Drillers, INC PHONE209-887-3554 <br />CONTRACTOR ADDRESS P.O. BOX 64 Cm'/STATEfZIPL i nd en CA 95236 <br />SUBCONTRACTOR/CONSULTANT <br />SUBCONTRACTOWCONSULTANT ADDRESS _ <br />LICENSE k C-57 L; C-61 D D-09 <br />BILLING PARTY: OWNER <br />Other <br />CONTRACTOR <br />CITYISTATEIZIP- <br />NUMBER 377923 <br />❑ SUBCONTRACTOR/CONSULTANT <br />PHONE <br />EXPIRATION DATE 7 / 31 / 23 <br />DOMESTIC WELL SAMPLING: G General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) ❑ Arsenic (4393) <br />INTENDED USE L. Domestic/Private nigation/Agricuttural L Industrial 0 Water Quality Monitoring a Soil Sampling/Characterization <br />0 Public Water System <br />If different from Owner. Water System Name Contact Name or Phone Number <br />I TPE VF WORK New Well G Replacement Well [1 Well Alteration/Modification N Other <br />Monitoring Well(s) # of wells 0 Soil Boring(s) # of borings 0 Geotechnical # of borings <br />Out -Of -Service Well �ii,yOut-Of-Service Well Renewal 0 Cross -Connection Repair <br />ryr <br />New Pump E Pump Replacement Pump Repair 0 Raise Well Casino <br />Drilling Method : Mud Rotary ❑ Air Rotary '- Auger Cable Tool Push Point „ Other <br />Proposed Well Depth ft Excavation in diameter J Open Bottom D Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Schad .2 Steel L' Plastic 0 Stainless Steel I, Other <br />Grout Seal Depth ft 0 Neat Cement (94 /b bag/- 70 gal water) C Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) 0 Other <br />Grout Placement Method :1 Pumped ❑ Free Fall C Other Retardant / Accelerator (name) <br />PEDESTAL Installed By = Driller - Pump Contractor C Other <br />1 Concrete Pedestal =Dimensions: Width it Length it Thick in 0 Christy Box L Stove Pipe <br />PUMP ; I Submersible Turbine 0 Other HP ZAO D1Cf44 Pump Set It Standing Water Level I q 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 ALL <br />WORKERS COMPENSATION LAWS. <br />N <br />m <br />D <br />O <br />m <br />m <br />H <br />M R I N r C N I L J C V N L T <br />Application Accepted By r+ C C Date Area Employee ID# <br />Grout Inspection By Date Cl SPECIAL Well Permit <br />Pump Inspection By fr;�"L'A s L 4.:J) h L Data `I I lIV l P t ( D WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth fl <br />COMMENTS <br />PE <br />Codes <br />Sc Received <br />Info <br />Check#! AmountPermit/ <br />Cash Remitted `Dat Service Re uest # Invoice # Well ID# <br />f'u <br />O S r7 <br />Sa- 1 <br />cnu csaro aR u[ury � � /jL <br />30 WELL /PUMP PERMIT <br />ll � ��s� <br />