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r <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (2091468 RAX <br />NUN-KEFUNDABLE PERMIT www.sigov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />JOBADDRESs16800 N Alpine Rd CrrY1ZIPLOdi.CA 95240 <br />CROSS STREET Victor Rd APN 05137013 PARCEL SIZE7 . 5 7 LAND USE APPLICATION # <br />OWNERNAME Joe_ GOt -1 1 i & qQns PHONE <br />OWNER ADDRESS _9189 N Achla3; Tn CITY/STATEIZIPStnckf-nnrCA 95212 <br />CONTRACTOR Purviance Drillers, INC PHONE209-887-3554 <br />CONTRACTOR ADDRESS P-0- BOX 64 _ CITY/STATFJZIPLinden CA 95236 <br />SUBCONTRACTORICONSULTANT <br />SUBCONTRACTORICONSULTANT ADDRESS <br />LICENSE 5R' C-57 C-61 it D-09 ;; Other <br />BILLING PARTY: OWNER CONTRACTOR <br />CITY/STATEMP_ <br />NUMBER 377923 <br />i SUBCONTRACTORICONSULTANT <br />PHONE <br />EXPIRATION DATE 7/31 / 21 <br />DOMESTIC WELL SAMPLING: C General Mineral/Coliform Bacteria (4391) ; Dibromochloropropane (4392) L Arsenic (43931 <br />WENDED USE Domestic/Private—f4rrigadordAgricultural :I Industrial --'Water Quality Monitoring C Soil Sampling/Characterization <br />Public Water System <br />If different from Owner. Water System Name Contact Name or Phone Number <br />rvew even L. Keplacement Wen F Well Alteration/Modification ❑ Other <br />7 Monitoring Well(s) # of wells " Soil Boring(s) # of borings Geotechnical a of borings <br />Out -0f -Service Well Out-OfService Well Renewal '; Cross -Connection Repair <br />L New Pump Pump Replacement L Pump Repair -; Raise Well Casino <br />Drilling Method _] Mud Rotary Air Rotary G Auger Cable Tool Push Point Other <br />Proposed Well Depth ft Excavation— <br />in diameter I Open Bottom :1 Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter 1 Conductor Casing Depth ft <br />Well Casing Diameter _ in Thfckness/Gauge/ASTM Sched Steel Ci Plastic � Stainless Steel [ I Other <br />Grout Seal Depth ft Neat Cement (94 Ib bagl5-10 gal water) Sand Cement sack mixl7 gal water <br />Bentonite (20% solids) :3 Other <br />Grout Placement Method -: Pumped Free Fall G Other Retardant / Accelerator (name) <br />PEDESTAL Installed By - Driller Pump Contractor C Other <br />Concrete Pedestal _Dimensions: Width ft Length ft Thick In ^ Christy Box C Stove Pipe <br />PUMP ubmersihle'; Turbine C Other HIP.�Z Pump Set ft Standing Water Level <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 />Application Accepted B L "'i <br />" <br />PP P Y — � — Date T v'6 � Area � / EmployeelD# <br />Grout Inspection By Date -1 SPECIAL Well Permit <br />Pump Inspection By % '� t Date l % l iii WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth <br />COMMENTS <br />PE <br />Codes <br />SC Received Check#/ Amount Date <br />Into B Cash Remitted <br />Permit/ <br />Service Request# Invoice# WellID# <br />lZS7o7�Z� <br />WELL !PUMP PERMIT <br />