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1 <br />w <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />NON-REFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />JOBADDRESS 5232 N Fine Rd CITYZPLinden,CA 95236 <br />CROSS STREET. S t Rt Hwy 2 6 APN _0a3 0 7 0 0 7 PARCEL SIZE .1 9 ..r4AND USE APPLICATION # <br />OWNERNAME Ed Giannecchini Rd PHONE <br />OWNERADDRESS 6889 N Wall Rd CrrYISTATEMP Linden. CA 95236 <br />CONTRACTOR Purviance Drillers, INC PHONE209-887-3554 <br />CONTRACTOR ADDRESS P - O- BOX 64 Clry/srATEZPLinden CA 95236 <br />SUBCONTRACTOR/CONSULTANT PHONE <br />SUBCONTRACTOR/CONSULTANT ADDRESS CITYISTATEMP <br />UCE14SE X C-57 - C-61 _ D-09 ; Other NUMBER 377923 EXPIRATION DATE 7/31/21 <br />BILLING PARTY: OWNER :: CONTRACTOR j SUBCONTRACTOR/CONSULTANT <br />DOMEsrc WELL SAMPLING: E. General Mineral/Coliform Bacteria (4391) ,:, Dibromochloropropane (4392) ❑ Arsenic (4393) <br />INTENDED USE i Domestic/Private(Inigation/Agricultural , Industrial _ Water Quality Monitoring U Soil Sampling/Characterization <br />tl Public Water Syst <br />If different from Owner. Water System Name Contact Name or Phone Number <br />ilea rveo t_ meplacemen[ Wen - well AlteratlOnfModRlCation _J Other <br />Monitoring Well(s) # of wells 0 Sol Boring(S) # of borings ❑ Geotechnical # of borings <br />Out -Of -Se vice�Wq _ Out -Of -Service Well Renewal a Cross -Connection Repair <br />New Pump_ �CPump Replacement Pump Repair _ Raise Well rasion <br />Drilling Method Mud Rotary - Air Rotary i Auger Cable Tool Push Point . Other <br />Proposed Well Depth ft Excavation in diameter i Open Bottom ru Gravel Pack/Gravel Size in diameter <br />. Conductor Casing in diameter ! Conductor Casing Depth it <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched - Steel ❑ Plastic C Stainless Steel J Other <br />Grout Seal Depth ft 7 Neat Cement (94 1b bag/5-10 gal water) C Sand Cement sack mW7 gal water <br />1. Bentonite (20% solids) J Other <br />Grout Placement Method ❑ Pumped i7 Free Fall L Other �i Retardant I Accelerator (name) <br />PIEDESTAL Installed By _ Driller _ Pump Contractor L' Other <br />Concrete Pedestal CDimensions: Width it Length it Thick in ❑ Christy Box Stove Pipe <br />PUMP i Submersihl?X—Turbine :� Other HP C Pump Set C7 It Standing Wat Level lm5e� e <br />I HEREBY CERTIFY THAT f" 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 AIN IN COMPLUWCE WITH ALL <br />WORKERS COMPENSATION.LAWR, <br />E NO'n('=- PEOMR1 <br />/ <br />Application Accepted BY DEPARTMENT <br />� USES ONLY <br />Date Aa 'cf'-C-� Employee Ip# <br />Grout Inspection By atm ' I SPECIAL Well Permit <br />Pump Inspection By ❑ WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth It <br />COMMENTS <br />m <br />m <br />D <br />A <br />N <br />SC Received <br />iv <br />Permit!Inf Remitted a Servide Re uest # Invoice # Well ID# <br />72 <br />"'� 1. <br />tChAmount <br />:Ww <br />an rro, <br />r <br />` - _ r�/ / • / �/d � / /� WELL Nniw PERMIT <br />RECp4ely,.r <br />EIVEp <br />APR 15 2021 <br />SAN JOAQUINENV <br />pE C <br />TYHEALTHATARNT <br />