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r <br />r WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />NON-REFUNDABLE PERMIT www.sigov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />JOBADDRESS 18291 E Front St CITY17rP Linden,CA 95236 <br />CROSS STREET Pllryi anc e Ln C APN 09120043 PARCEL SIZE 1 2 . 4 6r,ND USE APPLICATIONU# � <br />OWNERNAME Poggio Bros f��.�;�'•Iv-.au�1a7 3 4 'rR PHONE A <br />�J T <br />OWNERADDRESS 18201 E Front St CrmSTATE21PLinden,CA 95236 <br />CONTRACTOR Purviance Drillers, INC PHONE209-887-3554 <br />CONTRACTOR ADDRESS P. O. BOX 64 CrrYISTATEIZIPLinden CA 95236 <br />SUBCONTRACTORICONSULTANT PHONE <br />SUBCONTRACTORICONSULTANT ADDRESS CITY/STATE21P <br />LICENSE k C-57 C-61 ❑ D-09 Other NUMBER 377923 EXPIRATION DATE 7/31 / 2.j <br />BILLING PARTY: OWNER :j CONTRACTOR SUBCONTRACTORICONSULTANT <br />DOMESTIC WELL SAMPLING: i General MineraUColiform Bacteria (4391) :_! Dibromochloropropane (4392) ❑ Arsenic (4393) <br />INTENDED USE Domestic/Pdvate Irrigatlon/Agricultural Industrial C Water Quality Monitoring C Soil Sampling/Characterization <br />_ Public Water System <br />If different from Owner. Water System Name Contact Name or Phone Number <br />rre Ur vvOHrt .. rvew vven i. Replacement Well Ci Well Alteration/Modification E Other <br />Monitoring Well(s) # of wells 77 Soil Baring(s) it of bodrgs Geotechnical ft of borings <br />J Out -Of -Service Well .�'-J/Out-Of-Service Well Renewal ❑ Cross -Connection Repair F <br />J New Pumo :: Pumn Renlacement li/pumn Rwnnir r. Q.fon IAfen rid.... <br />Drilling Method Mud Rotary I Air Rotary C" Auger II Cable Tool ;; Push Point I., Other Q <br />Proposed Well Depth ft Excavation in diameter l Open Bottom ❑ Gravel Pack/Gravel Size iq diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft Q /)f J <br />Well Casing Diameter _ in ThicknesslGauge/ASTM Schad Steel 2 Plastic Stainless Steel it Other� <br />Grout Seal Depth ft 'INeat Cement (94 lb bag/5-10 gal water) Sand Cement sack mixl7 g <br />J Bentonite (20% solids) 0 Other <br />Grout Placement Method Pumped Free Fall C Other Retardant / Accelerator (name) <br />EDESTAL Installed By [; Driller _ Pump Contractor L Other <br />Concrete Pedestal ':Dimensions: Width ft Length ft Thick in r] Christy Box ri Stove Pipe <br />PUMP Submersible:; Turbine J Other HP Pump Set R 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 COMPLJANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />DEPARTMENT USE ONLY C <br />Application Accepted By C�� L Date ) Area (� Employee 1D4 ,�s <br />Grout Inspection By Date IPECIAL Well Permit <br />Pump Inspection By r �� i fir Date s [� ❑ WAIVER Received <br />I <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />N <br />m <br />D <br />O <br />N <br />EC MFNT <br />Fj QED <br />VG 1 ?021 <br />QCI(N <br />OI �MENO�NT y <br />EPgRT�0N7' <br />PE <br />Codes <br />SC Received Check#! Amount <br />Info Cash Remitted <br />]Date; <br />Permit/ <br />a ice uest Invoice # Well ID# <br />E'L) <br />-0 �a­1.11714� <br />I d <br />cnu aeuo arirtuia <br />WELL !PUMP PERMIT <br />