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' ► <br />,t SAN . WELUPUMP PERMIT <br />NON -REF -REFUNDABLE PERMIT N COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />WWW.S OV,Or /ehd EXPIRES i YEAR FROM DATE ISSUED <br />F0.NENA <br />103>JFairchild Rd <br />cITY/ZIP Stockton, CA 95215 <br />PARCEL SIZE ., _LAND USE APPLICATION # <br />N Vignolo Rd APN 0890802 <br />Bruce Ghio I <br />ADDRESS 1229 Rosemarie Ln Ste #A <br />CTOR Purviance Drillers, INC <br />CONTRACTOR ADDRESS P - 0 • BOX 64 <br />PHONE Off) <br />CITY/STATE/ZIP Stockton, CA 95207 <br />PHONE209-887-3554 <br />CITY/STATE/Z,PLinden CA 95236 <br />'mown 1 KAt: t UHIGONSULTANT <br />PHONE <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />CITY/STATEILP <br />LICENSE X C-57 C-61 D-09 a Other NUMBER 377923 7/31/23 <br />BILLING PARTY: EXPIRATION DATE <br />OWNER r�CONTRACTOR _. SUBCONTRACTOWCONSULTANT <br />LIOMESTIC WELL SAMPLING: 1: General Mineral/Coliform Bacteria (4391) = Dibromochloropropane (4392) C Arsenic (4393) <br />INTENDED USESyLpomestiurrivate Irrigation/Agricultural Industrial Water QualityMonitoring <br />{{ Public Water System Soil Sampling/Characterization <br />L It Elrteranl from Owner.Water System Name <br />Contact Name or Phone Number / <br />TYPE OF WORK ❑ New Well C Replacement Well Well Alteration/Modification Other <br />O Monitoring Wells) # of wells Soil Boring(s) T ofborings <br />❑ Out -Of -Service Well -1 Geotechnical Cofborings <br />Out-OfService Well Renewal Cross -Connection Repair <br />New Pum - um Replacement 7 Pum Repair <br />WELL LL Raise Well Casings <br />Drilling Method Mud Rotary ;; Air Rotary Auger .: Cable Tool Push PointOther— <br />Conductor <br />HE CNV/ <br />Proposed Well Depth Other <br />p ft Excavation in diameter , i Open Bottom Gravel Pack/Gravel Size— <br />CJ Conductor Casing in diameter / Conductor Casing Depthin diame e� <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched tt <br />Grout Seal Depth ft "Neat Cement (94 /b bag/S10 ga! water Steel Plastic Stainless Steel : I Other <br />Bentonite (20% solids) 7 Other % Sand Cement sack miX17 gal water' <br />Grout Placement Method : Pumped Free Fall 1: Other <br />Retardant /Accelerator Inamel <br />installed By Driller Pump Contractor G Other <br />Concrete Pedestal -Dimensions: Width ft Length g <br />in t' Christy Box .] Stove -pe <br />PUMP (Submersible : Turbine Other <br />HP Pump Set _ ft i%it <br />r <br />I HEREBY CERTIFY THAT I NStanding Water Level AVE 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 AND ACTIVE <br />S, <br />SIGNED .� / ,EASE CAl—i_ <br />TITLE_Z. '7,�04 - /� OL.c <br />DATE <br />L/ DEPARTMENT USE ONLY <br />Z_ -AL1_ <br />Application Accepted By - Date_ 1- { <br />f Area / Employee ID# %%) 5 <br />Grout Inspection By Date J SPECIAL Well Permit <br />Pump Inspection By _'k,-a!n5(p (�.n1� gy ✓a Date �,`�Jf; Z <br />i 1 1 WAIVER Received <br />Soil Boring Inspection By Date <br />COMMENTS Constructed Well Depth ft <br />EHD43-06 6/112019 <br /># Invoice # Well ID# <br />W ELL !PUMP PERMIT <br />Fc MFH <br />Ntij �O <br />:pq�Nr �NTy <br />MFNT <br />