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1 � I <br />WELUPUMP PERMIT <br />SAN JOAOUIN 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 1651N Beecher Rd <br />Cm21P Stockton, CA 95212mm <br />CROSS STREET 4;1- R i H W)f 26 APN 1 n 3 0 2 0 0 9 PARCEL SizE1 0 7- 3 4AND USE APPLICATION # <br />OWNER NAME F & S Solari / Kevin Solari PHONE <br />OWNER ADDRESS 91.22 Alpine Rd Cm/STATEmP_ Stockton, CA 95212 <br />CONTRACTOR Purviance Drillers, INC PHONE209-887-3554 <br />CONTRACTOR ADDRESS P-0- BOX 64 CrTY/STATEOPLinden CA 95236 <br />SUBCONTRACTORICONSULTANT <br />TANT ADDRESS <br />CrTY/STATE/ZJP <br />LICENSE R C57 C-61 7 D-09 Other NUMBER 377923 ExPtRATIoN DATE 7/ 31 /2 1 <br />BILLING PARTY: : ` OWNER 7 CONTRACTOR a SUBCONTRACTOR/CONSULTANT <br />DoNlEsnc WELL SAMPLING:(, General Mineral/Coliform Bacteria (4391) :? Dibromochloropropane (4392) ❑ Arsenic (4393) <br />PHONE <br />INTENDED USE a Domestic/Private XIrfigafion/Agriculturat ei Industrial ❑ Water Quality Monitoring i' Soil Sampling/Characterization <br />Public Water System <br />If different from Omer. Water System Name Contact Namrt or Phone Number <br />.—K ._ rvew even i.: replacement wen .i Well Alteration/Modification i Other <br />Monitoring Well(s) # of wells Soil Boring(s) If of borings ; Geotechnical It of borings <br />Out -Of -Service Well Out -Of -Service Well Renewal a Cross -Connection Repair <br />Drilling Method = Mud Rotary .: Air Rotary ❑ Auger ❑ Cable Tool ; : Push Point i7 Other <br />Proposed Well Depth ft Excavation in diameter a Open Bottom D Gravel Pack/Gravel Size in diameter <br />__ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Schad : Steel CJ Plastic D Stainless Steel iJ Other <br />Grout Seal Depth ft = Neat Cement (94 lb bag/5-10 gal water) ^_ Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) 2 Other <br />Grout Placement Method Pumped _i Free Fall is Other Retardant) Accelerator (name) <br />PEDESTAL Installed By Driller �: Pump Contractor C Other <br />Concrete Pedestal ':Dimensions: Width ft Length ft Thick in 7, Christy Box C Stove Pipe <br />PUMP C Submersibi .._ Turbine Other HP -1-4 Pump Set h 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 COMPENSATIO LA <br />1 NfrT1^E R> rMY MED FOR INISPEC?InNP - Pl SASE CALF <br />SIGNED t TITLE e, LL.`f+ c1. L l(�,tZ w DATE <br />vA <br />71 <br />aN <br />FNv <br />go ?�21 <br />/ 4 QV/ <br />44Ty�t� qN�O �NTY <br />MFNT <br />DEPARTMENT USE ONLY <br />Application Accepted By r` Lam` Date ) �$ Area C` Ir Employee ID# _ <br />Grout Inspection Byy Date 1 SPECIAL Well Permit <br />Pump Inspection By _ ?75L'� j -Ift _ Date Z 7 WAIVER Received <br />i <br />Sal Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />PE SC Received <br />Codes Info <br />Cheek#/ <br />Cash <br />Amount Date <br />Remitted <br />Permit/ Invoice # Well ID>Z <br />Service R uest# <br />J � - <br />- , JI i <br />..,` <br />IP <br />/fj I <br />23" <br />C.�/ / 6-7,2,WELL IPIIMP PERMIT <br />