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s <br /> 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.smqc)v.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 12440 Tully Rd <br /> CrrrILPLodi TCA 9540 m <br /> CROSSSTRM Harney Ln O <br /> y APNO 6 5 0 4 01 3 PARCEL$IZE9_S 7 LAND USE APPLICATION# p <br /> OWNERNAME Nicole Beadl c y <br /> PHONE rn <br /> OWNER ADDRESS 12440 T ,11v Rr1 CrTY1STATE/LP Lod i.CA 95240 <br /> CONTRACTOR Purviance Drillers, INC PHONE 2 0 9-8 8 7-3 5 5 4 <br /> CONTRACTOR ADDRESS P-0- Box 64 CfTY1STATr0pLinden CA 95236 <br /> SUBCONTRACTORICONSULTANT PHONE <br /> SUBCONTRACTORICONSULTANT ADDRESS CITY/STATE/ZIP <br /> LICENSE $C-57 7 C-61 ; D-09 Other NUMBER 377923 EXPIRATION DATE 7/31/21 <br /> BILLING PARTY: I OWNER L CONTRACTOR is SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:%General Mineral/Coliform Bacteria(4391),-1 Dibromochloropropane(4392)I7 Arsenic(4393) <br /> INTENDED USE omestic/Private ❑Irrigation/Agricultural 'I Industrial i!Water Quality Monitoring F Soil SamplinglCharacterization <br /> Public Water System <br /> If different from Owner:. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK 7 New Well r:Replacement Well I Well Alteration/Modification Other <br /> Monitoring Well(s) #Of wells SCII Boring(s) #of borings ;;Geotechnical #.f borings <br /> Out-Of-Service Well i Out-Of-Service Well Renewal I i Cross-Connection Repair <br /> New Pum _Pum Replacement Pum Re air r:Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary Auger C Cable Tool t.Push Point L� Other <br /> Proposed Well Depth ft Excavation in diameter :I Open Bottom F.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 _Plastic �Stainless Steel -I Other <br /> Grout Seal Depth ft 'Neat Cement(94 lb bag/5-10 gal water) _Sand Cement sack mrx/7 gal water <br /> Bentonite(20%solids) 3 Other <br /> Grout Placement Method :: Pumped Free Fall C Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By ;;Driller L:Pump Contractor L Other <br /> C Concrete Pedestal GDimensions:Width ft Length ft Thick In i;Christy Box 7,Stove Pipe <br /> PUMP Submersible:']Turbine 7 Other HP Pump Set It Standing Water Level k(n i 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 /> - - <br /> SIGNEDC�- -�CLJi.r`..i: TITLE ... .— DATE 121,7i•7/ <br /> a <br /> ------------ <br /> ------------------------------ <br /> Ec�jENT <br /> E/VE p <br /> ------------- <br /> N3� ?0?1 <br /> QUIN C <br /> I� Y%olvpgRTMEou NTy <br /> o l <br /> +#———————————— <br /> DEPARTMENT USE ONLY k� <br /> Application Accepted By i— r Date Area l�( <br /> 9 Employee ID# �v <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Perrnid <br /> Codes Info Cash Remitted Date Service Re uest# Invoice# Well ID# <br /> Y� 0'_u 2 1 <br /> EH0 43-06 6111=19 --f <br /> -75-7 2—I G WELL/PUMP PERMIT <br />