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• WELUPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCK -TON CA 95205-6232 (2091468-342( <br />NUN-KEFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUES <br />JOB ADDRESS 1 �iFn F. (nmatnrk Rrj aTrrzip Linden,CA 95236 <br />CROSS STREET Tully Rd APN O 91 1 5 0 01 PARCEL SIZE <br />1 9,-ZLAND USE APPLICATION # <br />OWNERNAME Ken Vogel PHONE <br />OWNERADDRESS 7322 PP7.7.i Rd CITY/STATE/ZIPStockton, CA 95215 <br />CONTRACTOR Purviance Drillers, INC PHONE209-887-3554 <br />CONTRACTOR ADDRESS P.O. Box 64 ___ CrrvISTATE21PL i nden CA 95236 <br />SUBCONTRACTORICONSULTANT <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />LICENSE X C-57 �j C-61 ,' D-09 <br />BILUNG PARTY: II, OWNER <br />CRY/STATE/LP <br />!! Other NUMBER 377923 <br />G CONTRACTOR I_1 SUBCONTRACTORICONSULTANT <br />PHONE <br />ExPIRATION DATE 7/31/23 <br />DOMESTIC WELL SAMPLING: 11 General Mineral/Coliform Bacteria (4391) !1 Dibromochloropropane (4392) ❑ Arsenic (4393) <br />INTENDED USE _ Domestic/Private Irrigation/Agricultural Li Industrial ii Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />If different from Owner. Water System Name Cantact Name or Phone Number <br />TYPE OF WORK New Well C Replacement Well Well Alteration/Modification : Other <br />Monitoring Wells # of wells Soil Boring(s) # of borin s <br />-1 Geotechnical dor borings <br />Out -Of -Service Well Out -Of -Service Well Renewal E Cross -Connection Repair <br />_. New PumD '. Pumn RAMIA—mant V,,a„r,,., Po i, - o.,,.... rnr_u <br />Drilling Method :' Mud Rotary ;_ Air Rotary C Auger -; Cable Tool L' Push Point , I Other <br />Proposed Well Depth ft Excavation in diameter a Open Bottom U Gravel Pack/Gravel Size__{ <br />Conductor Casing in diameter / Conductor Casing Depth ftHE v <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Schad i I Steel i1 Plastic ' 1 Stainless Steel 1 Other A <br />Grout Seal Depth ft Neat Cement f94 lb bag/S10 gal water) '_1 Sand Cement sack mixr7 gal water <br />Bentonite (20% solids) D Other <br />Grout Placement Method E Pumped .; Free Fall ❑ Other _ Retardant / Accelerator (name) <br />PEDESTAL Installed By _ Driller -. Pump Contractor L Other <br />Concrete Pedestal 7Dimensions: Width ft Length ft Thick in ' Christy Box Stove Pipe <br />PUMP Submersible Turbine :� Other HP Pump Set�qO it Standing Water Level , ft <br />I HEREBY CERTIFY THAT 1 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 />DEPARTMENT USE ONLY <br />Application Accepted By �� ` _ Data 1 Z)/,Y; ) Area y (' Employee ID# I <br />Grout Inspection By Date 1 SPECIAL Well Permit <br />Pump Inspection By Date i ti I WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />m <br />D <br />v <br />z <br />w <br />ANT <br />�® <br />4 ?021 <br />NT Nry <br />I R rM�N r <br />PE Sc Received Check#/ <br />Codes Info Cash <br />Amount Permit/ <br />Remitted Date Seryice a ueat # Invoice # Well ID# <br />05 E/112019 9 / 33 /� / � L � WELL IPUh1P PERMR <br />