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WELLIPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1668 EAST HAZELTON AVENUE -STOCKTON CA 95205 -6232 (209)468-U20 <br />NON-REFtINnARI F PFRMrr .. r..l...l <br />JOBADDRESS 21335 Eastern Heights Rd cRY21P Linden,CA 95236 <br />CROSS STREET Fine Rd APN 10522004 PARCEL SIZE dtELLAND USE APPLICATION # <br />OWNERNAME Tom Gaines <br />PHONE <br />OWNER ADDRESS 21335 Eastern Heights Rd Cm/STATE/ZIPLinden,CA 95236 <br />CONTRACTOR Purviance Drillers, INC PHoNE209-887-3554 <br />CONTRACTOR ADDRESS P.O. BOX 64 CITY/STATE/ZIPLlnden CA 95236 <br />SUBCONTRACTOR/CONSULTANT PHONE <br />SUBCONTRACTORICONSULTANT ADDRESS CRY/STATE/ZIP <br />LICENSE X C-57 C-61 :: D-09 :: Other NUMBER 377923 EXPIRATION DATE 7/31 /21 <br />BILLING PARTY: _-. OWNER -:CONTRACTOR I; SUBCONTRACTOWCONSULTANT <br />DOMESTIC WELL SAMPLING: [ . General Mineral/Coliform Bacteria (4391) -1 Dibromochloropropane (4392) 1; Arsenic (4393) <br />INTENDED USE _ omeslic/Private - Inigation/Agricultural i , Industrial 7 Water Quality Monitoring E Soil Sampling/Characterization <br />Public Water System <br />11 different from Owner Water System Name Contact Name or Phone Number <br />TYPE OF WORK -: New Well C Replacement Well E Well Alteration/Modification Other <br />Monitoring Well(s) # of wells C Soil Boring(s) # or twangsGeotechnical a of borings <br />Out -0f -Service Well C Out-OfService Well Renewal Cross -Connection Repair <br />New Pump ij Pump Replacement XPumR Repair Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method Mud Rotary ❑ Air Rotary ! i Auger ."7 Cable Tool = Push Point Other <br />Proposed Well Depth ft Excavation in diameter rl Open Bottom P Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Schad Steel G Plastic - Stainless Steel E Other <br />Grout Seal Depth ft Neat Cement (94 lb bag/5-10 gal water) 7 Sand Cement sack mW7 gal water <br />Bentonite (20% solids) :3 Other <br />Grout Placement Method Pumped Free Fall C Other Retardant / Accelerator (name) <br />PEDESTAL Installed By = Driller _ Pump Contractor C Other <br />Concrete Pedestal ::Dimensions: Width ft Length it Thick in i'. Christy Box : Stove Pipe <br />51Pump Set l 't -­� It Standing Water Level 7 ft <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SW <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. F <br />DEPARTMENT USE, 0NLY <br />Application Accepted By �� 1- L % Date C ��' iJP�I Area / I Employee ID# <br />Grout Inspection By Date 11 SPECIAL Well Pennit <br />Pump Inspection By Date E WAIVER Received <br />Sail Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />to <br />m <br />m <br />D <br />0 <br />m <br />N <br />YMENT <br />CEIVED <br />EP 2 1 2020 <br />JOAQUIN COUNTY <br />VVIRONMENTAL <br />LTH DEPARTMENT <br />WELL /PUMP PERMIT <br />1 Received <br />Amount Tlitt <br />Remitted <br />1��37If�U�11�R'/f�`!L'1a7►7�OI;d/,1l�^.Service <br />I1�11L'IGL��, - <br />WELL /PUMP PERMIT <br />