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WELUPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 -6232 (209) 468-342( <br />NUN -REFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />JOBADDRESS 8338 N_ Al n; ne Rd CITY/ZIP$tOCktOn, CA 9521 5 <br />CROSS STREET roppiano Ln ApN08903003 PARCEL SIZE33.57 <br />LAND USE APPLICATION # <br />OWNERNAME Steve Sanguinetti PHONE <br />OWNERADDRESS 18802 E Copperopolis Rd CITY/STATE21PLinden,CA 95236 <br />CONTRACTOR Purviance Drillers, INC PHONE209-887-3554 <br />CONTRACTOR ADDRESS P - 0. BOX 64 CIT./STATE/ZIPLinden CA 95236 <br />SUBCONTRACTORICONSULTANT PHONE <br />SUBCONTRACTOR/CONSULTANT ADDRESS Cr YISTATEIIIP <br />LICENSE X C-57 C-61 - D-09 Other NUMBER 377923 EXPIRATION DATE 7/ 3 1/ 2 1 <br />BILLING PARTY: _.: OWNER CONTRACTOR ; SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: C General Mineral/Coliform Bacteria (4391) ;I Dibromochloropropane (4392) I I Arsenic (4393) <br />WENDED USE DDmestic/Private ;�/-Inigation/Agricultural C Industrial C Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />If different from Owner. Wafer System Name Contact Name ar Phone Number <br />r y yryyUKK New vveii I . IKeplacement Well Well Alteration/Modification -, Other <br />Monitoring Well(s) #of wells :' Soil Borings) kofborings 1 Geotechnical mof bo ngs <br />Out -Of -Service Well Out -Of -Service Well Renewal C: Cross -Connection Repair <br />-: New Pump ❑ Pump Replacement :�jLPump Repair fRaise Well Casino <br />WFI I r:nNSTRIICTKIN <br />Drilling Method Mud Rotary D Air Rotary Auger Cable Tool _ Push Point Other <br />Proposed Well Depth ft Excavationin 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 Schad I' Steel Plastic Stainless Steel -I Other <br />Grout Seal Depth ft " Neat Cement (94 /b bag/5-10 gal Water) I : Sand Cement sack mix/7 gal water <br />Bentonite (20 % solids) a Other <br />Grout Placement Method Pumped : ; Free Fall C Other Retardant / Accelerator (name) <br />PEDESTAL Installed By ;:: Driller - Pump Contractor L: Other <br />Concrete Pedestal GDimensions: Width ft Length ft Thick in Christy Box Stove Pipe <br />j El <br />PUMP Submersibley Turbine C Other HP Pump Set ft Standing Water Level `14, @ <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 COMPI IANCF WITH At <br />to <br />M <br />D <br />°o <br />m <br />ur <br />DEPARTMENT USE ONLY <br />Application Accepted Byl [ Date �` �% Area Employee ID#� <br />Grout Inspection By Date I SPECIAL Well Permit <br />Pump Inspection By Date i 1 WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />PE <br />Codes <br />SC Received <br />Info <br />Check#/ Amount Permit/ <br />Cash Remitted a[e Service R St Invoice # Well ID# <br />-Vi <br />Z7 <br />WELL 1PUMP PERMIT <br />F FNT <br />SFO <br />to <br />COO <br />iNTy <br />�MFNT <br />