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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />LE PERMIT <br />JOB ADDRESS 6814 N Duncan RD CnvmP Linden,CA 95236 <br />CROSS STREET C i em RdI1CW. 0-1X. k APK 0 91 2 4 0 0 2 PARCEL SIZE3 4 . 3 4 LAND USE APPLICATION # <br />OWNERNAME Ralph Croce PHONE <br />OWNERADDRESS 16533 L Hwy 26 CITY/STATE/ZIP Linden,CA 95236 <br />CONTRACTOR Purviance Drillers, INC PHoNE209-887-3554 <br />CONTRACTOR ADDRESS P- 0. BOX 64 Crry/STATEMPL i nd en CA 95236 <br />SUBCONTRACTORICONSULTANT <br />SUBCONTRACTORICONSULTANT ADDRESS <br />y( G-57 U C-61 U D-09 <br />PARTY: C OWNER <br />PHONE <br />CiITYISTATEIZIP <br />� i Other NUMBER 377923 EXPIRATION DATE 7/ 3 1/ 2� <br />CONTRACTOR 11 SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: C General MineraVColiform Bacteria (4391) 0 Dibromochioropropane (4392) F Arsenic (4393) <br />INTENDED USE Domestic/Private 0)4(rrigation/Agricultural C: Industrial U Water Quality Monitoring U Soil Sampling/Characterization <br />Public Water System <br />If adferent from Owner. Water System Name Contact Name or Phone Numbrs <br />I YPE OF WORK _: New Well C Replacement Well Well AfterationlModification U Other <br />Monitoring Well(s) # of wells :]Soil Boring(s) a of b°"ne' ❑ Geotechnical # of bodn93 <br />Out -Of -Service Well n Out -Of -Service Well Renewal t' Cross -Connection Repair <br />New Pumo C Pumo Reolacement 1CPumo Renair n Raiaw Wwll Casino <br />ISSUED <br />Drilling Method - Mud Rotary _' Air Rotary U Auger Cable Tool U Push Point U Other <br />Proposed Well Depth ft Excavation in diameter U Open Bottom ii Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched F' Steel 71 Plastic U Stainless Steel -1 Other <br />Grout Seal Depth It C, Neat Cement (94 Ib bag/5-10 gal water) U Sand Cement sack mixf7 gal water <br />G Bentonite (20% solids) 0 Other <br />Grout Placement Method ' Pumped Free Fall ['. Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller -- Pump Contractor L Other <br />Concrete Pedestal Dimensions: Width <br />It Length It Thick in i Christy Box U Stove Pipe <br />PUMP Submersible' urbine _ Other HP Pump Set ft Standing Water Level ft <br />I HEREBY CERTIFY THAT I AVE 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 COMPE SATION LAWS. <br />i,?4 —F 14:' T ICS n7.� .11r'rT" . �s- - r e 7,-•! ^+ ^ r^r- <br />1/�� ..... . _. .. ._ . - <br />SIGNED-1c� TITLE CC,�' DATE <br />1'M 1EN tI <br />,EI a,Etd <br />03 2021 <br />7UIN COUN I Y <br />DEPARTMENT USE ONLY <br />Application Accepted By �-"Date Area � ` Employee ID# <br />Grout Inspection By Date (] SPECIAL Well Permit <br />Pump Inspection By Y Date WAIVER Received <br />Soil Boring inspection By Date Constructed Well Depth It <br />COMMENTS <br />PE SC Received CheckW <br />Codes Info C h <br />Amount D e Permit/ Invoice# Well ID# <br />Remitted S nice R uest # <br />i .:,O <br />% 22q (LIS <br />6111=19 + 12A 9-e S --? Y? �C)( 24,) 2— ` WELL/PUMP PERMIT <br />