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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAzELTON AVENUE - STOCKTON CA 95205 -6232 (209) 4663420 <br />NUN-KEFUNDABLE PERMIT WWW.$ Ov.Ot• /ena t_1CF'IKt, T TEAR FROM UATE ISSUED <br />JOBADDRESS 10848 Copperopolis Rd CITY/zIPStockton,CA 95215 <br />CROSS STREET S. Patton Ave �+ APN 1 0 31 1 0 0 6 pARCEL SIZE - 5 LAND USE APPLICATION # <br />OWNERNAMEDOUCJ MCAurthur - (OKI Y pi ljtjjhiJs /� y� r( A:r fhur PHONE <br />OWNERADDRESS 10834 Copperopolis Rd cm/sTATE/zlPStocktonrCA 95215 <br />CONTRACTOR Purviance Drillers, INC pHONE209-887-3554 <br />CONTRACTOR ADDRESS P. O. BOX 64 CITY/STATEiZIPL i nden CA 95236 <br />TANT <br />PHONE <br />SUBCONTRACTORICONSULTANT ADDRESS CrY/STATE/LP <br />LICENSE X C-57 C-61 D-09 Other NUMBER 377923 ExPIRAnON DATE 7/ 3 1/ 2 1 <br />(BILLING PARTY: -i OWNER CONTRACTOR C SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: C General Mineral/Coliform Bacteria (4391) ' Dibromochloropropane (4392) i-1 Arsenic (4393) <br />NTENDED USE -21`Domestir/Private !Irrigation/Agricultural i; Industrial _ Water Quality Monitoring "1 Soil Sampling/Characterization <br />�0 Public Water System <br />If different fmm Owner. Water Spwrn Nam. Contact Name or Phone Number <br />TYPE OF WORK [' New Well r Replacement Well : Well Alteration/Modification it Other <br />Monitoring Well(s) # of wells -.Soil Borings) # of borings C Geotechnical # of bomgs <br />Out -Of -Service Well Out -Of -Service Well Renewal C. Cross -Connection Repair <br />New Pump Slump Replacement _: Pump Repair . Raise Well Casing <br />Drilling Method _ Mud Rotary .: Air Rotary :- Auger C Cable Tool Push Point t� Other <br />Proposed Well Depth R Excavation in diameter 0 Open Bottom F Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter 1 Conductor Casing Depth ft <br />Well Casing Diameter_ in Thickness/Gauge/ASTM Schad Steel C Plastic ❑ Stainless Steel -1 Other <br />Grout Seal Depth R _ Neat Cement (94 lb bagl540 gal water) Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) J Other <br />Grout Placement Method Pumped ! Free Fall C Other : ; Retardant / Accelerator (name) <br />PEDESTAL Installed By _ Driller : Pump Contractor C Other <br />Ci Concrete Pedestal --Dimensions: Width ft Length it Thick in •❑ Christy Box 11 Stove Pipe <br />PUMP Submersible 0 Turbine - Other HP Pump Set H�j it Standing Water Level ft <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 />/PEPARTMENT USE ONLY <br />Application Accepted By Date E s `Zw <br />Grout Inspection By i Date L <br />Pump Inspection By <br />Soil Boring Inspection By Date <br />COMMENTS 1ft,C (i r �(41'�I� !" l+l1 �1�1. F' I.,,%-1 r, 'et <br />Area Ll �`dP EmployeelD# <br />SPECIAL Well Permit <br />-1 WAIVER Received <br />Construct/ed Well Depth ft <br />L6.✓ Cit: �. v. i. it , j,.f;_-{�• _ <br />PE Sc Received <br />Codes Info <br />Check#/ <br />sh <br />Amount ate Permit/ Invoice # Well ID# <br />Remitted Service Rgquest # <br />EHD 43-06 6/11/2019 <br />WELL /PUMP PERMIT <br />