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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 /> NON-REFUNDABLE P MIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOBADDREss 6101 Hogan Ln CrTY21P LodIi,CA 95240 m <br /> CROSS STREET Furry Rd APN 06114003 PARCEL SIZE 1 7 4`_AND USE APPLICATION p <br /> A <br /> OWNERNAME Andr W DaG O PHONE y <br /> OWNERADDRESS 4302 N BePr,her RD CITY/STATE/ZIP Stockton,CA 95215 <br /> CONTRACTOR Purviance Drillers, INC PHONE209-867-3554 <br /> CONTRACTOR ADDRESS P-0• BOX 64 Crry/STATE21PLinden CA 95236 <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTORICONSULTANT ADDRESS CITYISTATE/ZIP <br /> LICENSE X C-57 7;C-61 i;D-09 ::Other NUMBER 377923 EXPIRATION DATE 7/31/23 <br /> BILLING PARTY: G OWNER ::CONTRACTOR J SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:C General Mineral/Coliform Bacteria(4391)�1 Dibromochloropropane(4392)1'Arsenic(4393) <br /> INTENDED USE _Domestic/PrivateXInigation/Agricultural (: Industrial Water Quality Monitoring I7 Soil Sampling/Characterization <br /> C Public Water Sys em <br /> If different from Owner: Water system Mama Contact Name or Phone Number <br /> TYPE OF WORK f,New Well C Replacement Well Well Alteration/Modification 7 Other <br /> D Monitoring Well(s) III of wells Soil Bodng(s) #ofbonngs Geotechnical eofborings <br /> D Out-Of-Service Well Out-0f-Service Well Renewal Cross-Connection Repair <br /> D New Pump XumpReplacement Pump Repair C Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method a Mud Rotary G Air Rotary L Auger :1 Cable Tool `;Push Point Other <br /> Proposed Well Depth ft Excavation in diameter ❑Open Bottom IJ Gravel Pack/Gravel Size in diameter <br /> 1'.Conductor Casing in diameter I Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched -!Steel L Plastic 'I Stainless Steel _1 Other <br /> Grout Seal Depth ft :;Neat Cement(941b bag/5-10 gal water) C Sand Cement sack m,x/7 gal water <br /> Bentonite(20%solids) J Other <br /> Grout Placement Method Pumped L�Free Fall ❑Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By =Driller _Pump Contractor L Other <br /> C Concrete Pedestal=Dimensions:Width ft Length ft Thick in E.Christy Box G Stove Pipe <br /> PUMP -Submersible_Turbine Other HP E�_:i Pump Set't S� ft Standing Water Level �r 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 /> r,my 1njrC NOTICE <br /> ._: - .. <br /> SIGNED <br /> amu- TITLE _-. DATE..`7�/--I I <br /> MENT <br /> TZE7CEIVED: <br /> I <br /> Ja 4 2021 <br /> AN D QUIN UNMENTAL#1 H SY <br /> _ i[ TH D[PARfMENT <br /> ,v <br /> DEPARTMENT USE ONLY <br /> Application Accepted By GL Date '?119 Area c.1 �t�" EmployeelD# F <br /> Grout Inspection By Date 1 SPECIAL Well Permit <br /> Pump Inspechon By �. vim_ Datet ✓ ( ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received eck#/ Amount Permit/Codes Into Remitted ate Service Re uest# Invoice# Well ID# <br /> i 3 o o - v yUl <br /> EHD43-06 611112019 r WELL(PUMP PERMIT <br />