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F] <br />.rWELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468.3420 <br />NON-REFUNDABLE PERMIT <br />WWW.§' OV.Or lehd EXPIRES 1 YEAR FROM DATE ISSUED <br />FOWNEIR <br />RESs 24775 N Mackville Rd <br />TREET�'Qlller Rd CITY/7rP AcampO, CA 95220 <br />APN 121 15015 PARCEL SIZE. 5 LAND USE APPLICATION <br />NAME rl'1m OSWaldADDRESS 24775 Mackville Rd PHONE <br />GTY/STATE21PAcampo,CA 95220 <br />CONTRACTOR Purviance Drillers, INC <br />PHONE209-887-3554 <br />CONTRACTOR ADDRESS P•0• BOX 64 Linden CA 95236 <br />CITY/STATE/ZIP <br />SUBCONTI2ACTOR%CONSULTANT <br />PHONE <br />LICENSE <br />OR/CONSULTANT ADDRESS <br />CnY/STATE2tP <br />C-57 :: C-61 , D-09 [; Other NUMBER 377923 7/31/23 <br />EXPIRATION DATE <br />; . �: OWNER <br />CONTRACTOR __ SUBCONTRACTORICONSULTANT <br />DOMESTIC WELL SAMPLING: G General Mineral/Coliform Bacteria (4391) - Dibromochloropropane (4392) 11 Arsenic (4393) <br />INTENDED USE omestic/Private ^ Irrigation/Agricultural _ IndusMal _Water Quality Monitoring ' Soii Sampling/Characterization <br />S Public Water System <br />if <br />cr'ffemnt from Owner. Water System Name <br />Contact Name or Phone Mumher <br />TYPE OR WORK New Well r' Replacement Well C Well Alteration/Modification <br />:: Other <br />Monitoring Well(s) # Of wells '.Soil Boring(s) g orborings <br />Out -Of -Service Well New Pum i Geotechnical +torborings <br />Out -Of -Service Well Renewal Cross -Connection Repair <br />Pump Replacement •C✓Pm­ Ro ;. <br />Drilling Method .- Mud Rotary I.: Air Rotary Auger ' Cable Tool Push Point CProposed Well Depth '" Other Al/� <br />P ft Excavation in diameter .-7 Open Bottom _I Gravel Pack/Gravel Size <br />P. Conductor Casing in diameter / Conductor Casing Depth n diame <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Schad ft <br />Grout Seal Depth Steel -: Plastic Stainless Steel ; I Other__ <br />eP ft :; Neat Cement (94 Ib bag/5-10 gal water) :". Sand Cement <br />Bentonite (20% solids) � Other Sack mix/7 gal water <br />Grout Placement Method Pumped L, Free Fall D Other <br />_: Retardant /Accelerator (name) <br />PEDESTAL Installed By -1 Driller L Pump Contractor L Other <br />G Concrete Pedestal EDimenslons: Width ft Length ft Thick <br />in t Christy Box Stove Pipe <br />(PUMP }Submersible:'. Turbine :Other <br />HP �_ p Set !'l t ,t atanding Water Level o_ ft <br />I HEREBY CERtIFY THATHAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. IALSO 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 />�-• ,tom..),-- nc .;,r- .. -..- - .. .., .-....., - - <br />SIGNED <br />DEPARTMENT USE ONLY <br />Application Accepted By Z— Date /y Area _ f r <br />employee ID# f <br />Grout. Inspection By Date �J SPECIAL Well Permit <br />Pump Inspection By ra:.r, L,; C+r /f,'� Date <br />1 WAIVER Received <br />Soil Boring Inspection By <br />COMMENTS Date Constructed Well Depth ft <br />Date <br />J-�-J <br />Invoice # <br />Well ID# <br />EH043.012 &iiao1e <br />1�3 / ��� � D�j WELL /PUMP PERh11i <br />rn <br />Im <br />a <br />0 <br />0 <br />A <br />N <br />F yMFN <br />CF1V� <br />p � <br />14 20?1 <br />�N <br />apgRT -,4 r <br />NT <br />