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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 />NUN-KEFUNDABLE PERMIT www.SJgov.Orglehd EXNIKE5 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 7401 N Cnx Rd Crry0PLinden ,CA 95236 <br />CROSS STREET Comstock Rd APN 091240';r) PARCEL SIZE_30 LAND USE APPLICATION # <br />OWNER NAME Brenda Donath PHONE <br />OWNER ADDRESS 7401 N Cnx Rf1 CrTY/STATEI7JP 7.i nd—',(A 95,236 <br />CONTRACTOR Purviance Drillers, INC PHONF209-887-3554 <br />CONTRACTOR ADDRESS P. O. Box 64 CrYlSrATE21PL i nden CA 95236 <br />PHONE <br />SUBCONTRACTORICONSULTANT ADDRESS CITYISTATE/ZIP <br />LICENSE k C-57 ❑ 0-61 i 0-09 _ Other NUMBER 377923 EXPIRATION DATE 7/ 3 1/ 2 1 <br />BILLING PARTY: Z1 OWNER CONTRACTOR = SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: C General Mineral/Coliform Bacteria (4391) 7 Dibromochloropropane (4392) ❑ Arsenic (4393) <br />NTENDED USE 1".Domestic/Private C Irrigation/Agricultural Industrial C Water Quality Monitoring [,,Soil Sampling/Characterization <br />Public Water System <br />If efferent from Owner. Water System Name Contact Name or Phone Number <br />TYPE OF WORK " New Well '; Replacement Well C Well Alteration/Modification C Other <br />Monitoring Well(s) #of wells J Soil Boring(s) 4 o borings n Geotechnical iF or borings <br />Out -Of -Service Well i7 Out -Of -Service Well Renewal Cross -Connection Repair <br />Drilling Method 7 Mud Rotary Air Rotary :� Auger Cable Tool t-* Push Point [ � Other <br />Proposed Well Depth ft Excavation in diameter J Open Bottom C Gravel Pack/Gravel Size in diamete <br />.: Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ In Thickness/Gauge/ASTM Sched . Steel !.; Plastic 1 Stainless Steel A Other 5 <br />Grout Seal Depth ft C Neat Cement (94 lb bagIS-10 gal water) ": Sand Cement sack mixl7 gvl <br />Bentonite (20% solids) 0 Other <br />Grout Placement Method 7 Pumped - Free Fall C Other ^ Retardant / Accelerator (name) C <br />PEDESTAL Installed By C Driller �: Pump Contractor G Other <br />Concrete Pedestal r7Dimensions: Width ft Length ft Thick in !] Christy Box Stove Pipe <br />PUMP Submersible:. Turbine C Other HP 1 Ya„ Pump Set \rCt R Standing Water Level 1G, :-, 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 I AM IN COMPLIANCE WITH ALL <br />DEPARTMENT USE ONLY <br />DA <br />Application Accepted By �- 1,L Date Area r r Employee ID# <br />rInspection By Date IJ SPECIAL Well Permit <br />Pump Inspection By -� . ,-y Date ❑ WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />E yMF <br />4R ? <br />3,902, <br />E q'R ��NTY <br />NT <br />PE <br />Codes <br />Sc Received <br />Info B <br />ChecldN Amount <br />Cash Remitted <br />Date Permit/ Invoice # Well ID# <br />ervice uest# <br />q3e:� <br />o;� <br />4: 7 - <br />-?z <br />I <br />EHD43-0e 6 /1 112 0 7 97 [.3 <br />�/ �� l WELL(PUMP PERMIT <br />