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I r WELUPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />W1911� <br />1 YEAR FROM <br />JOSADDRESS 2 865 Kpp Wplr•h CITY/ZIP Lindpn,CA 95236 <br />CROSS STREET D i e t r i C k Fid APN 10921039 PARCEL SIZE2 - 4 7 LAND USE APPLICATI ON # <br />OWNER NAME Mike P1.1 7s, PHONE 1' (%)l 3 <br />OWNER ADDRESS P.O. BOX 848 CITY/STATE/ZIP Linden, CA 95236 <br />CONTRACTOR Purviance Drillers, INC PMONe209-887-3554 <br />CONTRACTOR ADDRESS P - O• BOX 64 Cm/STATEMPLinden CA 95236 <br />ADDRESS <br />LICENSE � C-57 C: C-61 I D-09 <br />BILLING PARTY: _ OWNER <br />PHONE <br />Clry/STATEIZIP <br />Other NUMBER 377923 ExPIRATON <br />CONTRACTOR SUBCONTRACTOR/CONSULTANT <br />7/31/21 <br />DOMESTIC WELL SAMPLING: i- General MineraMoliform Bacteria (4391) C Dibromochloropropane (4392) ❑ Arsenic (4393) <br />INTENDED USE l.. omestic/Private is Inigation/Agricultural [j Industrial Water Quality Monitoring ❑ Soil Sampling/Characterization <br />Public Water System D <br />If different from Owner; Water System Name Contact Name or Phone Number <br />TYPE OF WORK '_ New Well G Replacement Well D Well Alteration/Modification il Other R f� <br />7 Monitoring Well(s) # of wells D Soil Boring(s) # or borings Geotechnical # or borings <br />Out -Of -Service Well D Out -Of -Service Well Renewal D Cross -Connection Repair MAR New Pum XPum D Replacement Pum Repair L Raise Well Casing��1 <br />WELL CONSTRUCTION J <br />.Drilling Method _- Mud Rotary :; Air Rotary _i Auger Cable Tool Push Point Other SAN JoA <br />Proposed Well Depth ft Excavation in diameter 0 Open Bottom ❑ Gravel Pack/Gravel Size HF+Yr^d�af�1� <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ In Thickness/Gauge/ASTM Sched C; Steel 11 Plastic :] Stainless Steel I I Other <br />Grout Seal Depth ft Neat Cement (941b bag15-10 gal water) Sand Cement sack mix17 gal water <br />L Bentonite (20% solids) ❑ Other <br />Grout Placement Method C Pumped -: Free Fall C Other Z Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller ii Pump Contractor L Other <br />Concrete Pedestal -Dimensions: Width It Length ft Thick inU Christy Box ❑Stove Pipe <br />PUMP ubmersible Turbine Other HP _ _ _ Pump Set J 7, It Standing Water Level k <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. 1 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 />DEPARTMENT USE ONLY <br />Application Accepted By Date -/) 6� Area Employee ID# F <br />Grout Inspection By Da 99 ❑ SPECIAL Well Permit <br />Pump Inspection By ate I"1 WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth It <br />COMMENTS <br />YMENT <br />:EIVED <br />052021 <br />vlly COUNTY <br />OMENTA <br />PART/WENT <br />PE Sc Received Check#/ <br />Codes Info B h <br />Amount Date Permit/Invoice # Well ID# <br />Remitted Service Request # <br />c5 5._ <br />7' <br />EHD43-08 8/11/2019 /% ff� / �1/ 333 <br />'7 0/ /j WELL/PUMP PERMIT <br />