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t ' - WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAzELTON AVENUE-STOCKTON CA 95205 -6232 (208) 46$-3420 <br />NUN-KEFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUE[) <br />JOB ADDRESS 83Z N Fine Fd CrY1Z1P T,i nripn., rA 95236, <br />CROSS STREET 3 rLgv p APN 0910201 6 PARCEL SIzE2 _ 4 LAND USE APPLICATION # <br />OWNERNAME Patricia Solari PHONE <br />OWNERADDRESS P -Q-_ BOX 454 CITY/STATErZIP-T i ndenr CA 95216 <br />CONTRACTOR Purviance Drillers, INC PHONE 2 09 -8 8 7 - 3 5 5 4 <br />CONTRACTOR ADDRESS P- O. BOX 64 CrrYlSTATE/ZIPL i nden CA 95236 <br />TRACTOR/CONSULTANT ADDRESS <br />X C-57 C-61 D-09 Other <br />PARTY: OWNER ;; CONTRACTOR <br />CI Y/STATEMP <br />NUMBER 377923 <br />ii SUBCONTRACTORICONSULTANT <br />PHONE <br />EXPIRATION DATE 7/31 / 21 <br />DOMESTIC WELL SAMPLING: t; General Mineral/Coliform Bacteria (4391) i i Dibromochloropropane (4392) C Arsenic (43931 <br />INTENDED USE Domestic/Private ; IrrigationlAgricultural Li Industrial Water Quality Monitoring ❑ Soil Sampling/Characterization <br />Public Water System <br />11 different from Owner: Water System Name Contact Name or Phm Number <br />I TPC uryyORK .. New vven , : Keplacement wen Well Alteration/Modification P: Other <br />= MonitoringWell(s) #of wells ^SoilBoring(s) #ofbonnps :, Geotechnical of borings <br />Out -Of -Service Well Out -Of -Service Well Renewal L Cross -Connection Repair <br />New Pump =Pump Replacement -i Pump Repair _ Raise Well Casino <br />Drilling Method Mud Rotary C Air Rotary ii Auger :; Cable Tool G Push Point : ] Other <br />Proposed Well Depth ft Excavation in diameter -1 Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched Steel E Plastic n Stainless Steel Ll Other <br />Grout Seal Depth ft 7 Neat Cement (94 Ib bag15 10 gal water) _D Sand Cement Sack m&!7 gal water <br />J Bentonite (20% solids) J Other <br />Grout Placement Method _' Pumped :: Free Fall I: Other Retardant / Accelerator (name) <br />PEDESTAL Installed By _ Driller L' Pump Contractor L Other <br />Concrete Pedestal L Dimensions: Width ft Length ft Thick in Christy Box C Stove Pipe <br />PUMP - Submersible:: Turbine _- Other HP= Pump Set ft Standing Water Level 1 -`' It <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 />ADVANCE NOTICE REQUIRED FOR 1714carGCTIONS _ PU9 AeF CALL ;'9(10` era -7c.,7: <br />SIGNEDTITLE DATE <br />DEPARTMENT USE ONLY <br />r /o <br />Application Accepted By /'G L L' Date-, Area ( Employee ID# <br />Grout Inspection By _Date 1 SPECIAL Well Permit <br />Pump Inspection By � �,D <br />_ L� ate L d ,l 1 WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />m <br />a <br />°v <br />X <br />a <br />A Y, <br />CF1V Al <br />l� <br />26 ?021 <br />?(J/A1 <br />COON <br />/V <br />;pq�r�Mr <br />WELL RUMP PERMIT <br />