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1 <br />WELUPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE • STOCKTON CA 95205 -6232 (209) 468-3420 <br />FROM DATE <br />ADDRESS 13828 N Locust Tree Rd C'-/ZIPLodi,CA 95240 <br />SS STREET Harnejr Ln APN 06315044 PARCEL SIZE 1 9 - 9 4 LAND USE APPLICATION # <br />IERNAME James Caminata III PHONE <br />IERADDRESS 7045 N Cox Rd CITY/STATE/ZIP Linden,CA 95236 <br />TRACTOR Purviance Drillers, INC PHONE209-887-3SS4 <br />TRACTOR ADDRESS P• 0• Box 64 CITY/STATEIZIPL i ride n CA 95236 <br />LTANT <br />TANT ADDRESS <br />LICENSE X C-57 D C-61 D-09 <br />BILLING PARTY: a OWNER <br />CITY/STATE/ZIP <br />Other NUMBER 377923 <br />._ CONTRACTOR i'. SUBCONTRACTORICONSULTANT <br />PHONE <br />EXPIRATION DATE 7/ 3 1/ 2 1 <br />DOMESTIC WELL SAMPLING: F General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) fi Arsenic (4393) <br />INTENDED USE Domestic/Private rrigation/Agricultural '� Industrial C Water Quality Monitoring i s Soil Sampling/Characterization <br />Public Water System <br />ff different from Owner. Water System Name Contact Name or Phone Number <br />TYPE OF WORK New Well F Replacement Well 1 Well Alteration/Modification " Other <br />Monitoring�Nell(s) # of wells O Soil Boring(s) 2 of borings .1 Geotechnical x of borings <br />Out -Of -Service Well li Out -Of -Service Well Renewal Cross -Connection Repair <br />VNew Pump _ Pump Replacement D Pump Repair Raise Well Casino <br />Drilling Method _ Mud Rotary Air Rotary Auger �] Cable Tool L Push Point L Other <br />Proposed Well Depth ft Excavation in diameter ; I Open Bottom fGravel PacktGravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Wall Casing Diameter in Thickness/Gauge/ASTM Sched " Steel C Plastic : Stainless Steel :i Other <br />Grout Seal Depth ft _; Neat Cement (941b bag/5-10 gal water) Sand Cement sack mixt7 gal water <br />Bentonite (20% solids) 13 Other <br />Grout Placement Method '_: Pumped Free Fall L Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller ..: Pump Contractor L Other <br />Concrete Pedestal _Dimensions: Width ft Length ft Thick in : Christy Box C Stove Pipe <br />PUMP ' Submersible)(Turhine Other HP Pump Set (O(7 ft Standing Water Level 1 t C— a <br />I HEREBY CERTIFY THAT 1 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 TH <br />WORKERS COMPENSATION CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />• i=,..11f� t:R , :, N CE. 0 1 Mf. r' 10 <br />SIGNED V�E ^ <br />, L ! �.� ..7.�%y l <br />DATE <br />DEPARTMENT USE ONLY <br />Application Accepted By h L- Date 7 / is % Area 14�� C� Employee ID# r f <br />Grout Inspection By Date ] SPECIAL Well Permit <br />Pump Inspection By Date1, �` t U 7 WAIVER Received <br />Soil Boring InspPect on By Date Constructed Well Depth ft <br />COMMENTS /t,/M1+L1I 1,NF'Q'�. 7 <br />m <br />m <br />D <br />0 <br />m <br />N <br />F yMFN <br />� CES NF1) <br />2021 <br />ARTMENT <br />PE SC Received Check#/ <br />Info Cash <br />Amount Permit/Codes <br />Remitted Dat Service Requer&# Invoice # Well ID# <br />L13 -90 . -) <br />iso <br />aiircWa <br />LW. <br />'(f/ /�^�/�,� ^� WELL/PUMP PERMIT <br />