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i I ` WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 -6232 (209) 468-3420 <br />NON-REFUNDABLE PERMIT <br />WWW.- OV.Or /ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />JOBADDRESS 11589 Sun Rd <br />CITYZPIl _ (-A-9')215 <br />CROSS STREEr Beecher RD APN10317007 <br />PARCEL SIZE 1�LgND USE APPLICATION # <br />OWNER NAME Da l P Wa 1 1 inTfq�-d <br />PHONE � L L <br />OWNER ADDRESS P,O, BOX 580787 CRI'/$ipTE/ZIP F'1 k rrnvP. CA 9S7SR <br />CONTRACTOR Purviance Drillers, INC <br />PHONE209-887-3554 <br />CONTRACTOR ADDRESSP•O. Box 64 Linden CA 95236 <br />CIN/STATE/LP <br />SUBCONTRACTORICONSULTANT <br />PHONE <br />SUBCONTRACTORICONSULTANT ADDRESS <br />CRYISTATE/ZIP <br />LICENSE XC -$7 ❑ C-61 a D-09 :_ Other NUMBER 377923 7/31/23 <br />EXPIRATION DATE <br />BILLING PARTY: F! OWNER .; CONTRACTOR <br />.. SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING; General MineraUColiform Bacteria (4391) - Dibromochloropropane (4392) C; Arsenic (4393) <br />INTENDED USE OmestiC/Private :: Inrga ONAgricultural : ; Industrial -- Water Quality Monitoring Sail Sampling/Characterization <br />_ Public Water System <br />If different from Owner. Water System Name <br />Contact Name or Phone Number <br />TYPE OF WORK (: New Well r7 Replacement Well ^ Well Alteration/Modification <br />;7 Other <br />MonitoringWell(s)_ 4 O wells SoilBoring(s) of borings <br />Out-OfServiceWell-1Geotechnical or borings <br />Out -Of -Service Well Renewal _ Cross -Connection Repair <br />rMqthNew Pum ;- Pum R'e lacement Pum Repair <br />od <br />CONSTRUCTION - Raise Well Casin <br />Mud Rotary ❑ Air Rotary Auger 7 Cable Tool Push Point Other <br />pthft Excavation in diameter 7 Open Bottom - Gravel Pack/Gravel Size <br />Conductor Casing in diameter / Conductor Casing Depth ftin diameter <br />ameter in ThicknesS/Gauge/ASTM Schad <br />rout Seal Depth Steel ;_; Plastic . Stainless Steel [ I Other <br />P ft Neat Cement (94 /b bag/5 10 ga/ water) Sand Cement <br />Bentonite (20% solids) "_1 Other sack mix/7 gal water <br />Grout Placement Method .: Pumped -- Free Fall P Other <br />Retardant /Accelerator (name) <br />PEDESTAL Installed By _ Driller L Pump Contractor L Other <br />:.-. Concrete Pedestal _Dimensions: Width ft Length ft Thick <br />in ; :Chrsty Stove Pipe <br />PUMP 1 --submersible.; Turbine Other <br />HP Pump Sett) p ft Standing Water Level g <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 />!'3r 1ADVANCE <br />rn <br />iA <br />J1 ver NI I mcly IIU.51=ONLY <br />Application Accepted By Date "! �� q ( / < <br />Area Employee ID# / ) / J <br />Grout Inspection By Date J SPECIAL Well Permit <br />Pump Inspection By /, y, L %�� Date <br />� - � WAIVER Received <br />Soil Boring Inspection By Date <br />COMMENTS Constructed Well Depth ft <br />Codes- --'-"' ^"" " Permit/ <br />Info asfi Remitted Dat ervice R ues Invoice # Well ID# <br />EHD 43.06 6111/2019 <br />WELL /PUMP PERMIT <br />