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02 li <br />SAE <br />f` -1E <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1666 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (2091499R49i <br />NUN -REFUNDABLE PERMIT WWW Sj OV Of /ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />JOBADDRESS 4746 Archerdale Rd CITYMIPTA nr9An, ('A q_5236 <br />CROSS STREET_ S t- Rt- HW y ?6 APN n g 1 1 1061 PARCEL SIZE 5. 0 LAND USE APPLICATION # <br />OWNERNAMEDaye Kni(`kPrhr)r-kPr PHONE <br />OWNERADDRESS P.0 -BOX 121 CITYISTATE/Z1Phin(9Pn f1h QS7"2r- <br />CONTRACTOR Purviance Drillers, INC PHONE209-887-3554 <br />CONTRACTOR ADDRESS P- O. BOX 64 crrY1STATE21PLi nden CA 95236 <br />$ C-57 <br />PARTY: <br />.TAUT ADDRESS <br />C-61 D-09 <br />i OWNER <br />PHONE <br />CITYISTATEIZIP <br />i.: Other NUMBER 377923 EXPIRATION DATE 7/31/21 <br />CONTRACTOR ;j SUBCONTRACTOWCONSULTANT <br />DOMESTIC WELL SAMPLING: G General Mineral/Coliform Bacteria (4391) Dibfomochloronronnne 143991 -1 ArEu ;, fn laity <br />WENDED USE DomeStlCIPrivate il Irrigation/Agricultural i.: Industrial " Water Quality Monitoring D Soil Sampling/Characterization <br />Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />.—.rcn L. nHIJIGeieuleni vveu ,- vvell AlteratlONMOOItication C Other <br />Monitoring Well(s) # of wells G Soil Boring(s) # of borings ❑ Geotechnical 9 of borings <br />Out -Of -Service Well C Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />C New Pump "- Pump Replacement 1' Pump Repair Raise Well Casino <br />Drilling Method Mud Rotary 1 Air Rotary D, Auger _ Cable Tool Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter 11 Open Bottom ❑ 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 Ib bag/5-10 gal water) ^ Sand Cement sack mix/`7 gal water <br />Bentonite (20% solids) ❑ Other <br />Grout Placement Method Pumped t- Free Fall f i Other Retardant / Accelerator (name) <br />PEDESTAL Installed By '� Driller Pump Contractor C Other <br />i Concrete Pedestal '--Dimensions: Width It Length ft Thick in " Christy Box L Stove Pipe <br />PUMP bmersiblei Turbine l] Other HP Pump Set l ft Standing Water Level $ <br />I HEREBY CER IFY 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. 1 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 />DEPARTMENT USE ONLY t�] 9 PA <br />Application Accepted By" Date (7,fish � Area t �j % Employee ID# <br />Inspection By A Date D SPECIAL Well Permit <br />Pump Inspection By Date (l WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />m <br />D <br />Mz <br />in <br />PE SC Received <br />Codes Info <br />Check#/ Amount <br />ash Remitted Date Permit/ WellID# <br />rvi e e u st # invoice # <br />EHD4MG 9!11/7014 <br />11,_ <br />`-�' /-«O7.47"66 7 <br />WELL /PUMP PERMIT <br />