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c I f <br />t r SAN JOApUINCOUNTY ENVIRONMENTAL HEALTH DEPARTWELL/PUMP PERMIT <br />NON-REFUNDA13LEPERMIT 1868EASiHAZELTONAVENUE-STocKTONCA95205-6232 (209)468-3420 <br />WWW,S OV.Of /ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 14310 N Clements Rd <br />Cm21P_L0di r( -A 95240 <br />CRO SS STREEr_K leman Ln APNQ5318008 <br />PARCEL SRE3 9 _4LAND USE APPLICATION # <br />OWNER NAME Max CoDello/ Rollin Ranch ----- <br />OWNER ADDRESS P. O. BOX 5 6 2 PHONE <br />CrrY/STATEiZIp L; nden CA 95236 <br />CONTRACTOR Purviance Drillers, INC <br />CONTRACTOR ADDRESS P • O • BOX 64 PHONE209-887-3554 <br />CITYISTATEIZ1pL i n d e n CA 95236 <br />SUBCONTRACTOR/CONSULTANT <br />SUBCONTRACTOR/CONSULTANT ADDRESS PHONE <br />CF Y/STATE/ZIP <br />LICENSE k C-57 :: G�1 _: 0.09 Other <br />NUMBER 377923 ExPIRATIONDATE 7/31/23 <br />BILLING PARTY: i _. OWNER-- <br />..:CONTRACTOR 7 SUBCONTRACTORICONSULTANT <br />DOMESTIC WELL SAMPLING_ t : General Mineral/Coliform Bacteria (4391) - DibromochlOropropane (4392) 1; Arsenic (4393) <br />INTENDED USE 7 DomesticlPrivate Inigation/Agricultural Industrial Water Quality Monitoring ;: Soil Sampling/Characterization <br />Public Water System <br />uQfrerentfromOwnar. Water System Name <br />Contact Name or Phone Number <br />TYPE OF WORK - New Well C Replacement Well J Well Alteration/Modification Other <br />Monitoring Well(s) # of wells 2 Soil Boring(s) of borings <br />.i Out -Of --Service Well Geotechnical Sof borings <br />❑ Out -Of -Service Well Renewal Cross -Connection Repair <br />' New Pump 'Pump ReDlacemant rI o......, o..__:_ <br />Drilling Method :_ Mud Rotary Air Rotary Auger :: Cable Tool - Push Point Other <br />Proposed Well Depth ft Excavation in diameter -I Open Bottom E Gravel Pack/Gravel Size <br />Conductor Casing in diameter / Conductor Casing Depth n diameter <br />Well Casing Diameter _ in Thickness/Gauge/ASTNI Sched ft <br />Grout Seal Depth ft Neat Cement (94 Ib bag/5-10 gal water Steel ; Plastic Stainless Steel :1 Other <br />J Bentonite (20% .lids) J Other % Sand Cement sack mix/7 gal water <br />Grout Placement Method ; Pumped Free Fall C Other <br />Retardant /Accelerator (name) <br />PEDESTAL installed By -_ Driller Pump Contractor L Other <br />Concrete Pedestal 7—Dimensions: Width ft Len th <br />9 ft Thick in Christy Box _Stove Pipe <br />PUMP Submersible`.; Turbine 'J Other _ I 1 <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WIL g ftDONE INnACCORDANCE WITH SAN <br />JOAOUIN 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 LAW$, <br />Date `7//` /a_ �' 1 <br />Area-- Employee ID# <br />Grout Inspection By <br />Date J SPECIAL Well Permit <br />DataPump Inspection By L / <br />Soil Boring Inspection By Date WAIVER Received <br />COMMENTS Constructed Well Depth ft <br />c:necm I Amount Permit/ <br />Info Kash Remitted Dat R g Invoice # <br />7 S..,,i e T uest # Well ID# <br />EHD 43-06 an trzots <br />�131�S3 <br />/ n wELL !PUMP PERMIT <br />