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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 4683420 <br />INyrt-KEFUNDABLE PERMIT —www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />JOBADDRESs 7151 E. Fairchild Rd CITYIZIP Stnc-kt-on,CA 95215 <br />CROSS STREET Ar a t a Rd APN 1 01 1 0 0 2 3 PARCEL SIzE7 •9 5 LAND USE APPLICATION # <br />OWNERNAME Andrew Da550 PHONE <br />OWNER ADDRESS 4302 N Beecher Rd CITY/STATE/ZIP Stnr-kt nnrCA 95215 <br />CONTRACTOR Purviance Drillers, INC PHONE209-887-3554 <br />CONTRACTOR ADDRESS P- 0- BOX 64 CITv/STATE21PLinden CA 95236 <br />ITRACTOR/CONSULTANT <br />TRACTOR/CONSULTANT ADDRESS <br />X C57 _ C-61 D-09 <br />PARTY: OWNER <br />CITY/STATE/ZIP_ <br />Other NUMBER 377923 <br />.I CONTRACTOR L] SUBCONTRACTORICONSULTANT <br />PHONE <br />EXPIRATION DATE 7/31/21 <br />DOMESTIC WELL SAMPLING: C: General Mineral/Coliform Bacteria (4391) t' Dibromochloropropane (4392) [-,Arsenic (4393) <br />WENDED USE = DomesticJPr'Ivate Irrigation/Agricultural Industrial _; Water Quality Monitoring C Soil Sampling/Characterization <br />Public Water System <br />H different from Owner. Water System Name Cmtacl Name w Phone Number <br />rvew even i . mepiacement wen G Well Alteration/Modification I Other <br />'1 Monitoring Well(s) # of wells D Soil Boring(s) A of borings -7 Geotechnical of borings <br />Out -0f -Service Well D al <br />Out -Of -Service Well Renew ❑ Cross -Connection Repair <br />C New Pump Pump Replacement D Pump Repair Raise Well Casino <br />Drilling Method = Mud Rotary = Air Rotary G Auger ] Cable Tool " Push Point ti Other <br />Proposed Well Depth ft Excavation in diameter ; i Open Bottom C Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter I Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM SchedSteel Ll Plastic L-3StainlessSteel -1 Other <br />Grout Seal Depth ft :: Neat Cement (94 /b bag15-10 gal water) Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) 2 Other <br />Grout Placement Method :_ Pumped 'i Free Fall C Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller -: Pump Contractor G Other <br />i- Concrete Pedestal '_!Dimensions: Width ft Length it Thick in Christy Box E Stove Pipe <br />PUMP :.: Submersible4urbind L Other HP �!J Pump Set \1 l_ ft Standing Water Level kyb _ 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 1 AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />J „,PE NOTICE REL•1'_' 7C FC:-`!�y!yISP_ --EAS <br />t CAL.'SIGNED �.6� .LG=.U'iJY.Ci TRLH� L'Csj" DATE G5-11? 22 <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />RTMENTSE NL) <br />Date <br />_ Date <br />Date l I Z <br />Date <br />Cn <br />M <br />D <br />0 <br />A <br />m <br />qr <br />f4r<1yU <br />�'o <br />aQt �j <br />F gFpl��NrY <br />MFNT <br />Area Employee ID# <br />EC <br />l PIAL Well Permit <br />.71 WAIVER Received <br />Constructed Well Depth ft <br />MN,W—Wil/1,//.J�//K��'�ilf7�l`71�►�I�li1L6It7�L�= <br />fla� �F ^�_ WELLIPUMPPERMIT <br />fla� �F ^�_ WELLIPUMPPERMIT <br />