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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 •6232 (2091468-3420 <br />NUN-KEFUNDABLE PERMIT www.sigov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 5473 N Beecher Rd tn-yiziastockton,CA 95215 <br />CROSSSTREET Baker Rd APN08912023 PARCEL SIZE <br />1 2 07 LAND USE APPLICATION # <br />OWNERNAME M & M Ranch PHONE <br />OWNER ADDRESS 2.0- Rnx 7 5 Q <br />CONTRACTOR Purviance Drillers, INC <br />CONTRACTOR ADDRESS P - D - BOX 64 <br />SUBCONTRACTORICONSULTANT <br />CIT1'/STATEmp Liriden,CA 95236 <br />PHONE209-687-3554 <br />CrTY/STATE/ZIPL i n d e n CA 95236 <br />PHONE <br />SUBCONTRACTOR/CONSULTANT ADDRESS CrrY/STATE/ZIP <br />LICENSE R C-57 C-61 i-' D-09 1. Other NUMBER 377923 EXPIRATION DATE 7/31/21 <br />BILLING PARTY: :I OWNER C CONTRACTOR LSUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: C General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) ❑ Arsenic (4393) <br />NTENDED USE Domestic/PrivateIrrigation/Agricuftural 1 --,Industrial Water Quality Monitoring 7 Soil Sampling/Characterization <br />Public Water System <br />If different from Owner Water System Name Contact Name or Phone Number <br />rvew Vveu i. mepiacement wen Well Alteration/Modification U Other <br />Monitoring Well(s) # of wells C Soil Boring(s) Sof Ings Geotechnical # of borings <br />Out -Of -Service Wefl Out -Of -Service Well Renewal 11 Cross -Connection Repair <br />New Pump (Pump Replacement [) Pump Repair C Raise Well Casino <br />Drilling Method !� Mud Rotary i' Air Rotary D Auger C Cable Tool 7 Push Point D Other <br />Proposed Well Depth ft Excavation in diameter E Open Bottom ❑ Gravel PacklGravel Size in diameter <br />Conductor Casing In diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Schad ❑ Steel LE Plastic ❑ Stainless Steel D Other <br />Grout Seal Depth ft E Neat Cement (94 /b bag/5-10 gal water) Sand Cement sack mW7 gal water <br />J Bentonite (20% solids) D Other <br />Grout Placement Method Pumped _ i Free Fall F Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller L: Pump Contractor E Other <br />Concrete Pedestal _Dimensions: Width ft Length ft Thick in ; Christy Box L; Stove Pipe <br />PUMP Submersible`': Turbin6 C Other HP Pump Setft Standing Water Level 17'7, fl <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 1 AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />:r�ci; Ivorlc� Ic�uttEASE c;: r� <br />SIGNED �rh-/,!/�GrCt /cCCJ TITLE ✓GCf-v'�7 DATE <br />m <br />D <br />a <br />S <br />N <br />ITEC M <br />l�/FNT VES <br />MA � 4 X021 <br />N JOA Q <br />a THUI[)EP,4R � TY <br />NT <br />EP RTMENT UAE/ONLY <br />Application Accepted By Date Area Employee ID# <br />�'5 <br />Grout Inspection By Date D PECIAL Well Permit <br />Pump Inspection By L Date L1 WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />Received Permit/ <br />Remitted ®.-5ervIce Request <br />1,2 '—J / — 75 LL WE!PUMP PERMri <br />