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SAN.IOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPAR WELUPUMP PERMIT <br />'1868 EAST tIAZELTON AVENUE-STOCKTON CA 95205 <br />NON-REFUNDABLEPERMIT -6232 (209) 468-3420 <br />WWW.S OV.Or lehd EXPIRES 1 YEAR FROM DATE ISSUED <br />FCROSSSTREET <br />DRESS '] D <br />Cm21PI,i ndf,n CA 95236 <br />_Coutgto k RD APN 09109001 <br />PwrtoeL 91ZE -12-1-1-AND USE APPLICATION # <br />OWNER NAME Varrarezza Bros ) -� <br />PHONE t, L <br />OWNER ADDRESS 8150 N Duncan RD <br />P_ 7 i n d P n CA 9 5 2 3 6 <br />CONTRACTOR Purviance Drillers INC CITY/STATE/ZI <br />PHONE209-887-3554 <br />CONTRACTOR ADDRESS P - 0 - BOX 6 4 <br />crrYISTATH2iPL i nd en CA 95236 <br />SUBCONTRACTOR/CONSULTANT <br />PHONE <br />..vo... iKACTOR/GONSULTANT ADDRESS <br />CITYISTATE/ZIP <br />LICENSE XC_57 - C -it D-09 Other377923 <br />NUMBER EXPIRATION DATE 7/31/23 <br />BILLING PARTY; . OWNER <br />�.: CONTRACTOR _ SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: C General Mineral/Coliform Bacteria (4391),- Dibromochloropropane (4392) E Arsenic I4a41i <br />Public Water Syste <br />If different from o ­ <br />Tvn <br />." Industrial <br />Water Quality Monitoring �, Soil Sampling/Charactedzation <br />Contact Nw ­.._.. <br />. i-epiacement Well ; <br />Monitoring Well(s) ; Well Alteration/Modification <br />Other <br /># of wells Soil Bodng(s) Tot borings <br />Out -Of -Service Well Geotechnical 4 of borings <br />Out -Of -Service Well Renewal Cross Connection Repair <br />New Pum - Pump Re lacement um Repair ,� <br />WELL CONSTRUCTION k- � �: Raise Well Casing <br />Drilling Method :-' Mud Rotary C Air Rotary � Auger .-' Cable Tool Push Point <br />Proposed Well Depth Other <br />P ft Excavation in diameter 7 Open Bottom L Gravel Pack/Gravel Size <br />- Conductor Casing in diameter / Conductor Casing Depth in diameter <br />Well Casing Diameterth in Thickness/Gauge/ASTM Sched ft <br />a <br />Grout Seal De Steel _: Plastic - Stainless Steel Other <br />P ft -; Neat Cement (94 lb bag/5-10 gal water) -: Sand Cement <br />Bentonite (20% solids) D Other sack mix/7 gal water <br />Grout Placement Method : ; Pumped Free Fall I ) Other <br />Retardant /Accelerator (name) <br />PEDESTAL Installed By _ Driller _ Pump Contractor G Other <br />Concrete Pedestal Dimensions Width ft Length ft Thick <br />m Christy Box Stove Pipe <br />PUMP Submersible*Turbine ;l Other HP Pump set <br />I HEREBY CERTIFY TAT I FIAV <br />JOAQUIN COHE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE E iDONEDINDACCORDANCE WITH SAN <br />UNTY 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 />? r r+rc t MrN 1 USE ONLY <br />Application Accepted By !. Date f y r• <br />Grout Inspection By Area I Employee ID# / / — <br />Date D /SPECIAL Well Permit <br />Pump Inspection ByDate l - <br />1 WAIVER Received <br />Soil Boring Inspection By Date <br />COMMENTS Constructed Well Depth fl <br />EHD43-06 6/11/2019 <br /># Invoice # I Well ID# <br />WELL /PUMP PERMIT <br />rn <br />0 <br />D <br />z <br />N <br />.e I <br />FNr <br />VCIO <br />COO <br />V7 -d <br />T MFNr <br />