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WELUPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAzELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />NUN-KEFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 19 J,a. Pat-t-prann A r0 CrrY2lp Stockton,CA 95215 <br />CROSS STREET _St Rt Hwy 26 APN 0 8 9 0 9 2 21., PARCEL Slzs . 6 9 LAND USE APPLICATION # <br />OWNER NAME Dan Dr)m l ng(-) PHONE <br />OWNERADDRESS -i-�Qj Wa}prwhppl Rd CITY/STATEMPEmmett, ID, 83617 <br />CONTRACTOR Purviance Drillers, INC PHONE209-887-3554 <br />CONTRACTOR ADDRESS P.O. BOX 64 CmISTATEMPL i nden CA 95236 <br />SUBCONTRACTORICONSULTANT <br />LICENSE k C-57 <br />BILLING PARTY: <br />.TANT ADDRESS _ <br />C-61 D-09 <br />,i OWNER <br />CITY/STATEMP <br />Other NUMBER 377923 <br />:.,CONTRACTOR L SUBCONTRACTOR/CONSULTANT <br />PHONE <br />ExPrRATION DATE 7/31/21 <br />DoMEsnc WELL SAMPLING: 1: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) L Arsenic (4393) <br />INTENDED USE XDomestictPrivate ❑ Irrigation/Agricultural i, Industrial 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 />TYPE OF WORK :. New Well L Replacement Well C Well AlterationlModiffcation Other <br />Monitoring Well(s) 9ofwelis ❑Soil Borings) dor wrings ❑ Geotechnical 0ofbftW <br />Out -Of -Service Well Out -Of -Service Weil Renewal i Cross -Connection Repair <br />New PumD C PUMD Reolacament "SJPmmn Ronair - pone toren r....:.,., e <br />Drilling Method __ Mud Rotary -Air Rotary Ci Auger Cl Cable Tool L Push Point 7. Other F v y/ <br />Proposed Well Depth ft Excavation in diameter a Open Bottom %1 Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Schad �] Steel L] Plastic t i Stainless Steel Ll Other <br />Grout Seal Depth it Neat Cement (94 Ib bag/5-10 gal water) C Sand Cement sack mix17 gal water <br />Bentonite (20% solids) J Other <br />Grout Placement Method - Pumped [; Free Fall L Other G Retardant! Accelerator (name) <br />PEDESTAL Installed By Driller � Pump Contractor L' Other <br />Concrete Pedestal I:Dimensions: Width ft Length ft Thick in L Christy Box C Stove Pipe <br />PUMP Submersible: 1 Turbine :_ Other HP 1 "':.a Pump Set .1 = ; ft 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 COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />DEPARTMENT USE ONLY <br />Application Accepted By ,7�' L ' C % Date S E. J Area f / (! Employee ID# DA <br />Grout Inspection By A Date _l SPECIAL Well Permit <br />Pump Inspection By ^ s Date 1 l V L1 WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />li <br />qc <br />MFNr <br />E��ED <br />Y0620 <br />21 <br />QU/N C <br />E q TMENTY <br />PE SC Received <br />Codes Info B <br />Check#! Amount Date PWMIV <br />ash Remitted rvice R est # Invoice # Well ID# <br />I,V <br />WELL !PUMP PERMIT <br />