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WELUPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />EXPIRES 1 YEAR FROM <br />ADDRESS N i Best...�?j r,t� ( CIYZP Stnr-kt-nnr('A 9521 5 <br />55 STREET C0ppPZ'C)nc)1 i C Ra APN � U`� PARCEL SIZE �LgND USE APPDCATION# <br />NAME <br />PHONE <br />OWNER ADDRESS 309—SQRt way CITY/STATEZP Stnr•ktnnrr'A 95215 <br />CONTRACTOR Purviance Drillers, INC pHoNp209-887-3554 <br />CONTRACTOR ADDRESS P - O, BOX 64 CITY/STATEZPLi nden CA 95236 <br />SUBCONTRACTOR/CONSULTANT <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />LICENSE k C-57 C-61 ❑ D-09 <br />BILLING PARTY: iJ OWNER <br />PHONE <br />CITY/STATEIZIP <br />Other NUMBER 377923 EXPIRATION <br />a CONTRACTOR li SUBCONTRACTORICONSULTANT <br />7/31/21 <br />DOMESTIC WELL SAM PUN G: G General Mineral/Coliform Bacteria (4391) 11 Dibromochloropropane (4 392) G Arsenic (4393) <br />INTENDED USE /ZDomesticfPdvate a Irrigation/Agricultural L Industrial ❑ Water Quality Monitoring L Soil Sampling/Characterization <br />Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK - New Well r' Replacement Well C Well Alteration/Modification E Other <br />Monitoring Well(s) # of wells " Soil Boring(s) x of bonn9s C Geotechnical n of borings <br />Out -Of -Service Well C' Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />New Pump Pump Replacement I_ Pump Repair :; Raise Well Casing <br />WELL CONSTRUCTION <br />AN <br />(Drilling Method r_' Mud Rotary :: Air Rotary Auger - t] Cable Tool � Push Point C Other i <br />Proposed Well Depth ft Excavation in diameter ] Open Bottom D Gravel Pack/Gravel Size ih I <br />Z Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Schad Steel r; Plasfic -i Stainless Steel 7 Other <br />Grout Seal Depth ft ❑ Neat Cement (94 lb bag/5-10 gal water) n. Sand Cement sack mixf7 gal wat9r <br />Bentonite (20% solids) D Other <br />Grout Placement Method -i Pumped i Free Fall C Other Retardant / Accelerator (name) <br />PEDESTAL Installed By _ Driller Pump Contractor ! Other <br />Concrete Pedestal i_]Dimensions: Width ft Length ft Thick in r j Christy Box C Stove Pipe <br />PUMP Submersible❑ Turbine Other HP Pump Set \ C 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 I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />7� DEPARTMENT SE ONLY <br />Application Accepted By T—/� Date 1 7 v' Area ~� ` / Employee iD#_ <br />Grout Inspection By Date 1 SPECIAL Well Permit <br />Pump Inspection By Data Z ❑ WAIVER Received, <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />Cn <br />D <br />a <br />N <br />4F YM�N ?` <br />CF1VE4) <br />I PR 08 20?1 <br />)AQtj0NMEc0VNTy <br />DEpaRTMeNT <br />PE <br />Codes <br />SC Received <br />Info <br />Check#/ Amount <br />Cash Remitted <br />Date <br />Per rm <br />Service Re U uest# Invoice # Well ID# <br />EHD 43-08 6111r1018 . ,1 371 S7� WELL /PUMP PERMIT <br />