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WELUPUMP PERMIT <br /> ` f SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232 (209)468-3420 <br /> NON-REFUNDABLE PERMIT www.s ov.or /ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 1024 Edan Ave Crry/ZIP Stockton,CA 95207 m <br /> CROSS STREET Pacific Ave APN 0 7 7 3 6 0 01 PARCEL SIZE .4 6 LAND USE APPLICATION# p <br /> A <br /> OWNERNAME Jarnh t=rppn PHONE Z4Fq- 7((J�/03- J�j7o m <br /> OWNERADDRESS 1024 F.t9an Ave Clrr/STATEZPStockton,CA 95207 <br /> CONTRACTOR Purviance Drillers, INC PHoNE209-887-3554 <br /> CONTRACTOR ADDRESS P-0. BOX 64 Cm,/srATEZPLinden CA 95236 <br /> SUBCONTRACTORICONSULTANT PHONE <br /> SUBCONTRACTORICONSULTANT ADDRESS CITY/STATEIZIP <br /> LICENSE �C-57 S C-61 :D-09 i Other NUMBER <br /> 377923 EXPIRATION DATE 7/31/23 <br /> BILLING PARTY: OWNER -1 CONTRACTOR ;:J SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING:L General Mineral/Coliform Bacteria(4391)11 Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE ,K Domestic/Private 7 Irrigaton/Agricultural Industrial C Water Quality Monitoring C Soil Sampling/Characterization <br /> Public Water System <br /> If different from O—er. Water System Name Contact Name a Phone Number <br /> TYPE OF WORK :;New Well L'Replacement Well _Well Alteration/Modification I Other <br /> Monitoring Well(s) #of wells Soil Boring(s) #of borings L-I Geotechnical #of borings <br /> Out-Of-Service Well L Out-Of-Service Well Renewal E Cross-Connection Repair <br /> New Pump Pum2 Replacement r, Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary 7 Air Rotary Auger i7 Cable Tool Push Point L Other <br /> Proposed Well Depth ft Excavation in diameter ❑Open Bottom C!Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched I:Steel ::Plastic J Stainless Steel !Other <br /> Grout Seal Depth ft ❑Neat Cement(94 Ib bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> Li Bentonite(20%solids) U Other <br /> Grout Placement Method ! Pumped .i Free Fall C Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By �;Driller E Pump Contractor L Other <br /> Concrete Pedestal!;Dimensions:Width ft Length ft Thick in CJ Christy Box n Stove Pipe <br /> PUMP Submersible^Turbine G Other HP Pump Set, ft Standing Water Level ft <br /> 1 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 /> -1,m\'I-r::r4n-Tli REQUIR77 FL'',}.ec r�.Ir}?� ,�rA$E CAI ? .�. <br /> SIGNED ^%Z`^^CiCGh!/x-!7K• TITLE dcc.¢.�-r <br /> DATE <br /> s <br /> Ila, I <br /> FF <br /> 7 <br /> RECEIVED <br /> OV 1 7 2021 <br /> JOAQUIN COUNT1f <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> / DEPARTMENT USE ONLY 1 <br /> Application Accepted By L Date r 1 /t . <br /> - XArea S�'-k4j Employee ID# tj <br /> Grout Inspection By Date 11 SPECIAL Well Permit <br /> Pump Inspection By Date Z 8'fe?-Z 11 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS_.;fWN 1 -t1" <br /> --FE--T—SC—T Received Check#/ Amount Permit/ <br /> Codes I Info Bv. .4ash Remitted .Date Service Request# Invoice# Well ID# <br /> EHD 43-06 6/11/2019 I Z / 2 L/ WELL/PUMP PERMIT <br />