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110 <br />SAN IOApUiNCOUNTYENVIRONMENTALHEALTHDEPARTMWEEUPUMP PERMIT <br />1868 EAST HAzELToN AVENUE - STOCKTON CA 95205 -6232 (209) 4683420 <br />NON-REFUNDABLE PERMIT <br />HrWW.S OV.Or /ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />FCRRE <br />9345 Henry Rd <br />T CITY/ZIP ckton CA 95206 <br />1 ArtPr Rr3 APN 20707024 <br />PARCEL SIZE _5 . 0 LAND USE APPLICATION # <br />Keith Derousse <br />PHONESS Henr RdPurviance Drillers, INCc'TY/STATrJZIP�tQ k on CA 95206 <br />DDRESS P-�. BOX 64 PHONE209-887-3554 <br />CRY/STATE/ZiPLinden CA 95236 <br />UBCONTRACTOR/CONSULTANT <br />PHONE <br />SUBCONTRACTORICONSULTANT ADDRESS <br />CI Y/STATE/ZIP <br />LICENSE filer C-57 C-61 :1 D-09 1 Other <br />NUMBER 377923 <br />BILLING PARTY; OWNER EXPIRATION DATE_ <br />C CONTRACTOR _ SUBCONTRACTORICONSULTANT <br />DOMESTIC WELL SAMPLING: L' General Mineral/Coliform Bacteria (4391) -; Dibromochloropropane (4392) C; Arsenic (4393) <br />INTENDED USE �Omestic/Private Irr' t' - <br />7/31/23 <br />ga .... Agricultural ; Industrial Water uality Monitoring it Soil Sampling/CharatrizationPublic Water SystemNdifferentfmmOwner System Name <br />TYPE OF WORK ❑ New Well G Replacement Well n e or Phone Number <br />Well Alteration/Modification _ OtherMonitoring Wells) # of wells Soil Boring(s) of boringsOut-Of-Service Well Geotechnical Mberin9s <br />Out -Of -Service Well Renewal Cross -Connection Repair <br />New Pump ump Replacement Pum, Ranair <br />unsling Method C Mud Rotary C Air Rotary ; Auger G Cable Tool Push Point <br />Proposed Well Depth Other <br />P ft Excavation in diameter ElOpen Bottom G Gravel Pack/Gravel Size <br />Conductor Casing in diameter I Conductor Casing Depth iIn <br />Well Casing Diameter in Thickness/Gauge/ASTM Schad ft <br />Grout Seal Depth ft -Steel is Plastic Stainless Steel a Other_ <br />Neat Cement (94 lb bag/5-10 gal water) Sand Cement <br />u Bentonite (20% solids) D Other sack mixr <br />Grout Placement Method pumped Free Fall C Other <br />7 Retardant /Accelerator (name) <br />PEDESTAL Installed By •_ Driller L Pump Contractor G Other <br />Concrete Pedestal ':Dimensions: Width ft Length ft Thick <br />in ❑Christy Box [7 Stove Pipe <br />PUMP Submersible :Turbine ' Other <br />HPQ Pump Set� I HEREBY CERTIFY THAT I HAVE ft Standing Water Level <br />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 REOUIRED LICENSE IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH Au <br />WORKERS COMPENSATION LAWS. <br />--• ter.. rvrC1Y I ust ONLY <br />Application Accepted By `C c - Date [ T/ti ✓' Area C� Cl (� <br />Grout Inspection By Employee ID# <br />Date <br />Pump Inspection By _] SPECIAL Well Permit <br />1 \ , I Z�-L <br />Date , D WAIVER Received <br />Soil Boring Inspection By Date <br />COMMENTS Constructed Well Depth ft <br />PAYMENT <br />RECEIVED <br />OCT 0 4 2021 <br />SAN JOAOUIN COUNTY <br />ENVIRONMENTAL - <br />HEALTH DEPARTMENT <br />