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f <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232 (209) 468-3420 <br />NkJN-KEFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />JoBADDRESs 4819 Duncan RD CITY21PLinden,CA 95236 <br />CROSS STREET St Rt Hwy 26 APN 09119010 PARCEL SIZE . 5 8 LANDUSEAPPLC ON # <br />OWNER NAME Chuck Ragg10 PHONE 5 '� r'I '� �� V � "3iL L <br />OWNERADDRESS P -O Box 591 CITYISTATEIZIPLinden, CA 95236 <br />CONTRACTOR Purviance Drillers, INC PHONE209-887-3554 _ <br />CONTRACTOR ADDRESS P - O - BOX 64 CITY/STATEZPLinden CA 95236 <br />SUBCONTRACTOR/CQNSULTANT <br />SUBCONTRACTORICONSULTANT ADDRESS _ <br />LICENSE $ C-57 C-61 C: D-09 is Other <br />BILLING PARTY: ti OWNER C CONTRACTOR <br />CnYISTATE/7JP <br />NUMBER 377923 <br />SUBCONTRACTORICONSULTANT <br />PHONE <br />EXPIRATION DATE 7/31/23 <br />DOMESTIC WELL SAMPLING:[-. General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) F, Arsenic (4393) <br />INTENDED USE Domestic/Private Ci Irrigation/Agricultural :i Industrial C] Water Quality Monitoring I] Soil Sampling/Characterization <br />Public Water System <br />If different from (Tuner: Water System Name Contact Name or Phone Number <br />I YPE OF WORK '..! New Well C Replacement Well C Well Alteration/Modification C] Other <br />Monitoring Well(s) _ # of wells C Soil Boring(s) # o1 borings I Geotechnical # or borings <br />Out -Of -Service Well : Out -Of -Service Well Renewal 0 Cross -Connection Repair <br />New Pump _7 Pump Replacement V Pump Repair "�_ �c k "']I. C Raise Well Casino <br />Drilling Method :. Mud Rotary Air Rotary 1 Auger Cable Tool Push Paint ,.! Other <br />Proposed Well Depth ft Excavation in diameter U Open Bottom L Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched !' Steel Plastic ' Stainless Steel ] Other <br />Grout Seal Depth ft ; Neat Cement (94 lb bag/5-10 gal water) Sand Cement sack mixr7 gal water <br />Bentonfte (20% solids) U Other <br />Grout Placement Method Pumped :! Free Fall L Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Z Driller L Pump Contractor U Other <br />Concrete Pedestal —Dimensions: Width ft Length ft Thick in Christy Box G Stove Pipe <br />PUMP 'Submersible❑ Turbine ❑ Other HP PumO Set `) ft Standing Water vel I % L.i It <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 />DEPARTMENT USE ONLY <br />Application Accepted By /`�=1 Date �E Area 1 �/ C Employee ID# <br />Grout Inspection By Date :1 SPECIAL Well Permit <br />Pump Inspection By L i ' ' C Date Z L D WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />PE Sc Received Check#/ <br />Codes Info C h <br />Amount Permit/ <br />Remitted Date S rvice Re uest # Invoice # Well ID# <br />f 17,Z 2 <br />EH043-06 6f11=19 / /7 �L �%/ n WELL !PUMP PERMIT <br />1S! ` <br />vlcr/Vr <br />Ep <br />CC)U?021 <br />TENry <br />NT <br />