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11 WELL/PUMP PERMIT <br />SAN JONQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />.4 <br />�dvld-r«rurvuAnLt rtKMI I www.sjgov.orglend EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 3880 Alpine RD ciwaIP Stockton, <br />CROSS STREET Fairchild APN 08908004 PARCEL SIZE LL —q—CND USE APPLICATION # <br />OWNERNAME Prieto Family Trust PHONE 209-482-6321 <br />OWNER ADDRESS 2328 Brittany Lane Lodi CA 95242 <br />CITY/STATE/ZIP , <br />CONTRACTOR Purviance Drillers, INC <br />CONTRACTOR ADDRESS P • O. BOX 64 <br />SUBCONTRACTOR/CONSULTANT <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />LICENSE X C-57 C-61 D-09 Other <br />BILLING PARTY: CI OWNER CONTRACTOR <br />PHONE209-887-3554 <br />CITY/STATE/ZIPL i nd e n CA 95236 <br />CITY/STATE/ZIP <br />NUMBER 377923 <br />SUBCONTRACTORICONSULTANT <br />PHONE <br />EXPIRATION DATE 7/31 /23 <br />DOMESTIC WELL SAMPLING: G General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) 1 Arsenic (4393) <br />INTENDED USE Domestic/Private X Irrigation/Agricultural Industrial Water Quality Monitoring - Soil Sampling/Characterization <br />_ Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />YPE OF WORK A1C New Well C Replacement Well Well Alteration/Modification ❑ Other <br />/� Monitoring Well(s) # of wells ❑ Soil Boring(s) a of borings Geotechnical u of borings <br />Out -Of -Service Well ❑ Out -Of -Service Well Renewal D Cross -Connection Repair <br />New Pump =: Pump Replacement - Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method �( Mud Rotary Air Rotary Auger Cable Tool Push Point - Other <br />Proposed Well Depth p p `) AW ft Excavation /9 /y in diameter Open Bottom i Gravel Pack/Gravel Size in diameter <br />Conductor Casing N fi- in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched a 26V 'Steel Plastic Stainless Steel I Other <br />Grout Seal Depth 300 t - ft Neat Cement (94 /b bag/5-10 gal water) XSand Cement /O. 3 sack mW7 gal water <br />Bentonite (20% solids) L Other <br />Grout Placement Method X Pumped Free Fall I Other Retardant / Accelerator (name! <br />PEDESTAL Installed By )CDriller Pump Contractor -L Other <br />,X Concrete Pedestal Dimensions: Width `' ft LaA h tta!! ft Thick in Christy Box Stove Pipe <br />PUMP Submersible - Turbine 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 />�L �kNCE NOTICE . 4.� ti��Lc _ r .i.aw (;409) <br />SIGNED i . TITLE Corporate Secretary DATE 8/4/21 <br />4�jD PARTMENT USE ONLY <br />RAPApplication Accepted By Date <br />Grout Inspection By Date <br />Pump Inspection By Date <br />Soil Boring Inspection By <br />COMMENTS <br />Date <br />T <br />m <br />D <br />0 <br />v <br />rn <br />m <br />cn <br />Area Employee ID# /'I <br />7 SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth • &,,, ft <br />PE Sc Received Check#/ Amount Permit/ <br />Codes I fo B Cash Remitted I D to Service Re ueSt # <br />invoice # qN O <br />�r WeIIdl�ifr <br />v 21 ) 2 1v <br />c o?v �o <br />'T <br />EHD 43-06 6/11/2019 (I�n"a}Vi'/t_ I , I 20 C-4- I -�q L ) WELL /PUMP PERMIT <br />