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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205.6232 (209) 4683420 <br />NUN-KEFUNDABLE IIERMIT www.sj Oy.or /ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 3237 Diinr-An_Rd cfTYrzIP Linden.CA 95236 <br />CROSS STREET_ _St Rt Hwy 2 6 APN 1 0509010 PARCEL SIZE 0. 6 LAND USE APPLICATION # <br />OWNERNAME Teed RPPVPR PHONE <br />OWNERADDRESS 3737 Ditnr-an Ra CrrY1STATE0PT,i nr'1Pn,('A 95 " 6 <br />CONTRACTOR Purviance Drillers, INC PHONE209-887-3554 <br />CONTRACTOR ADDRESS P-0- BOX 64 CrrY/STATEMPLinden CA 95236 <br />SUBCONTRACTORICONSULTANT <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />LICENSE X C-57 C-61 D-09 Other <br />BILLING PARTY: L� OWNER :i CONTRACTOR <br />CITYISTATERIP_ <br />NUMBER 377923 <br />F SIIBCONTRACTOR/CONSULTANT <br />PHONE <br />EXPIRATION DATE 7 / 31 / 21 <br />DOMESTIC WELL SAMPUNG: C General Mineral/Coliform Bacteria (4391), Dibromochloropropane (4392) G Arsenic (4393) <br />INTENDED USE Domestic/Private C Irrigation/Agricultural G Industrial Water Quality Monitoring D Soil Sampling/Characterization <br />Public Water System <br />If different from Owner. Water System Nama Contact Name or Phone Number <br />TYPE OF WORK New Well G Replacement Well D Well Alteration/Modification J Other Ac <br />Monitoring Well(s) #of wells L Soil Boring(s) #orbonngs P, Geotechnical #or borings " <br />Out -Of -Service Well U Out -Of -Service Well Renewal D Cross -Connection Repair <br />New Pump rump Replacement - Pump Repair C Raise Well Casino <br />Drilling Method = Mud Rotary L' Air Rotary D Auger :: Cable Tool Push Point ". Other ' <br />Proposed Well Depth ft Excavation in diameter I! Open Bottom ❑ Gravel Pack/Gravel Size Si>3a er <br />Conductor Casing in diameter / Conductor Casing Depth ft I�IvvR <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched : Steel ;; Plastic Stainless Steel [ I Other E <br />Grout Seat Depth ft .; Neat Cement (941b bag/5-10 gal water) Sand Cement sack mix17 gal wat <br />Bentonite (20% solids) D Other <br />Grout Placement Method Pumped Free Fall C Other C Retardant / Accelerator (name) <br />PEDESTAL Installed By C Driller �: Pump Contractor G Other <br />C; Concrete Pedestal `:Dimensions: Width it Length it Thick in Christy Box i I Stove Pipe <br />PUMP Aubmersibie Turbine � Other HP Pump Set ft Standing Water Level ft <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 1 AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />DEPARTMENT USE ONLY <br />Application Accepted Bye 7, , l L` Date i.T / Area ! �, Employee ID# d <br />Grout Inspection By ate n SPECIAL Well Permit <br />Pump Inspection Byi' ��_ Date n WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />SC IAmount , I Permit/ <br />Info Received # Dale IRemitted <br />I Invoice rI <br />Well ID# <br />so 1/,09 1 V/S6 1 i%I X <br />EMD43-06 E/1112019 � " � / � WELL (PUMP PERMIT <br />rn <br />D <br />0 <br />P <br />a y/tq' v7 <br />1/E6 <br />032021 <br />�J/N C <br />VI17FN°uNry <br />PAR7- <br />