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' WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />IY"rXMr UNUAt3Lt rtKml I www.sigov.org/ena EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 7021 N Escallon Bellota Rd CITY/ZIP Linden, CA 95236 <br />CROSS STREET Hwy 26 APN 0 9.3080/0 PARCEL SIZE '2y f'Z <br />LAND USE APPLICATION # <br />OWNERNAME George & Greg Gerlomes; Ralph Croce;John D MartPKY.1E <br />OWNERADDRESS 8464 N DeMartini Lane, CITY/STATE/ZIP Linden, CA 95236 <br />CONTRACTOR Purviance Drillers, INC PHONE209-887-3554 <br />CONTRACTOR ADDRESS P - 0 - BOX 64 CITYISTATE/ZIPL i nd e n CA 95236 <br />SUBCONTRACTOR/CONSULTANT PHONE <br />SUBCONTRACTORICONSULTANT ADDRESS CITY/STATE/ZIP <br />LICENSE X C-57 C-61 D-09 Other NUMBER 377923 EXPIRATION DATE 7/31 /23 <br />BILLING PARTY: OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) Arsenic (4393) <br />NTENDED USE Domestic/Private X Irrigation/Agricultural Industrial ❑ Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />YPE OF WORK X New Well Replacement Well ❑ Well Alteration/Modification Other <br />D Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings Geotechnical # of borings <br />❑ Out -Of -Service Well U Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />- New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method k Mud Rotary - Air Rotary Auger Cable Tool Push Point Other <br />Proposed Well Depth 6 ;?_� ft Excavation .2Z in diameter A Open Bottom Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter J4p in Thickness/Gauge/ASTM Sched .2S—Z)X Steel Plastic Stainless Steel i Other <br />Grout Seal Depth Dr ) ft Neat Cement (94 /b bag/5-10 gal water) Sand Cement /L� sack mix/7 gal water <br />Bentonite (20% solids) -_I Other <br />Grout Placement Method I Pumped Free Fall I Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Y Driller _ Pump Contractor _ Other <br />X Concrete Pedestal Dimensions: Width �o4 tid Length It Thick in Christy Box Stove Pipe <br />PUMP Submersible 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 I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />�jVANCE NOTICE REQUIRED F 11',!" <br />j <br />SIGNED QQ U e� �(,t{/s. yam, TITLE_ dM_0 DATE '('0 � <br />I`ll. DEPARTMENT USE ONLY <br />Application Accepted By �� ----! Date <br />Grout Inspection By ex— Date <br />Pump Inspection By Date <br />Soil Boring Inspection By Date <br />COMMENTS L;I)'1 ,A;V1 <(� ;CI<< ;ice hC~ZcyC%J�� �,nG^ •Ii o�sJ <br />Area % f I Employee ID# <br />J SPECIAL Well Permit <br />7 WAIVER Received <br />Constructed Well Depth fl <br />T <br />M <br />M <br />D <br />O <br />v <br />z <br />M <br />y <br />PE <br />Codes <br />SC Receive <br />Info <br />Check#/ Amount <br />C Remitted <br />Date Permit/ Invoice # Well ID# <br />Service Request # <br />WELL /PUMP PERMIT <br />