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I <br />WELUPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1666 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 466.1420 <br />PERMIT <br />.O <br />FROM DATE <br />JOBADDRESs 20601 E Kettl man rn CrY1ZIPLOd1.,CA 95240 <br />CROSS STREET Clements APN Q 5 3 1 9 0 0 2 PARCEL SIZE3_L8_,0_4AND USE APPLICATION # <br />OWNERNAME B0-thj -J Trpa�Farms-, 1;R - . be%vii 1 PHONE <br />OWNERADDRESS _2.3475 Lc)nq Val 1p)z Rr7 CITYISTATE/ZIFWa nr3lanrl Eli l l 5;; nn Q1 "4F,7 <br />CONTRACTOR Purviance Drillers, INC PHONE209-887-3554 <br />CONTRACTOR ADDRESS P.O. BOX 64 CrTYISTATE21PL i nden CA 95236 <br />SUBCONTRACTOR/CONSULTANT <br />SUBCONTRACTORICONSULTANT ADDRESS <br />LICENSE k C-57 C-61 D-09 <br />BILLING PARTY: OWNER <br />CITYISTATEMP <br />Other NUMBER 377923 <br />CONTRACTOR :i SUBCONTRACTORICONSULTANT <br />PHONE <br />EXPIRATION DATE 7 / 3 1 / 2� <br />DOMESTIC WELL SAMPLING: F General Mineral/Coliform Bacteria (4391) ,, Dibromochloropropane (4392) n Arsenic (4393) <br />INTENDED USE D Domestic/Private mgatiion/Agricultural :I Industrial C Water Quality Monitoring Soil Sampling/Charactenzation <br />Public Water System <br />If different from Owner: Water System Nam. Contact Name or Phone Number <br />YPE OF WORK 1. New Well F Replacement Well '.l Well AlterationlModification 17: Other <br />Monitoring Well(s) # of wells .7 Soil Boring(s) if of borings ❑ Geotechnical d of borings <br />Of <br />Out -Of -Service Well ; Out --Service Well Renewal J Cross -Connection Repair <br />- New Pump 1/,Pump Replacement Pump Repair r Raise Well Casino <br />WELL CONSTRUCTION j <br />Drilling Method : Mud Rotary :: Air Rotary Auger Cable Tcol .. Push Point Il' Other <br />Proposed Well Depth ft Excavation in diameter I Open Bottom D Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched Steel Plastic : i Stainless Steel Other <br />Grout Seal Depth ft _ Neat Cement (94 lb bag/5-10 gal water) i : Sand Cement sack mixl7 gal water <br />C Bentonite (20% solids) O Other <br />Grout Placement Method Pumped =: Free Fall ❑ Other Retardant / Accelerator (name) <br />PEDESTAL Installed By L Driller - Pump Contractor C Other <br />Concrete Pedestal ::Dimensions: Width ft Length It Thick in ❑ Christy Box r- Stove Pipe <br />Pump <br />Submersible :7 Other HP 300 Pump Set ft Standing Water Level 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 />y <br />m <br />D <br />M <br />4 <br />DEPARTMENTaUS ONLY <br />/ � Application Accepted By � Lf Date �) Area <br />Employee ID# j� J/ <br />Grout Inspection By 4 Date U SPECIAL Well Permit <br />Pump Inspection By Date ❑ WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />PAYMENT <br />RECEIVED <br />UG 0 3 2021 <br />IN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />EALTH USPARTMEN E <br />PE <br />Codes <br />SC Received <br />Info <br />Check#1 Amount D Permit/ <br />cash Remitted ale §Rrvice 13a uest # Invoice # Well ID# <br />3E'► <br />Own <br />/` < c <br />2_1I II Z �7-/Z&/� � � WELL !PUMP PERMIT <br />