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D <br />L <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />NUN <br />JOBADDRESS 4755 N archerdale Rd Crrr/7JPLinden,CA 95236 <br />CROSS STREET _rla)C—AV 2 APN 0 91 1 3 0 3 7 PARCEL SIZE 8 • 19 LAND USE APPLICATION # <br />OWNERNAMEBiff Gilliland PHONE <br />OWNERADDRESS 14404 E Hwy 26 CrTY/sTATEmPLinden, CA 95236 <br />CONTRACTOR Purviance Drillers, INC PHONE209-887-3554 <br />CONTRACTOR ADDRESS P - O. Box 64 CITY/STATEmPLl nden CA 95236 <br />PHONE <br />SUBCONTRACTOWCONSULTANT ADDRESS CITY/STATEmP <br />LICENSE $ C-57 C-61 _ D-09 Other NUMBER 377923 EXPIRATION DATE 7/ 3 1/ 2� <br />BILLING PARTY; _ OWNER 0 CONTRACTOR ; SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: G General Mineral/Coliform Bacteria (4391)'1 Dibromochloropropane (4392) E Arsenic (4393) <br />NTENDED USE i:., Domestic/Private V nigation/Agricultural _; Industrial Water Quality Monitoring C Soil Sampling/Characterization <br />Public Water Syste <br />ff rJlftereM from Owner- Water System Name Contact Name or Phone Number <br />ISSUED <br />YPE OF WORK New Well C Replacement Well D Well Alteration/Modification CI Other <br />Monitoring Well(s) # of wells D Soil Boring(s) # of bormp 1.. Geotechnical # of borings <br />Out -Of -Service Well I7 Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />:. New Pump _PumpVPump Replacement D Pump Repair _: Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method -. Mud Rotary .: Air Rotary Auger Cable Tool Push Point Other <br />Proposed Well Depth ft Excavation in diameter Ll 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 Schad ;: Steel i; Plastic ❑ Stainless Steel i1 Other <br />Grout Seat Depth ft = Neat Cement (94 Ib bag/5-10 gal water) Sand Cement sack mix/7 gal water <br />E Bentonite (20% solids) Other <br />Grout Placement Method :: Pumped J Free Fall C Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller L: Pump Contractor E Other <br />Concrete Pedestal -Dimensions: Width ft Length ft Thick in Christy Box ❑ Stove Pipe <br />PUMP .Submersible --i Turbine C Other HP Pump Set It Standing Water Level f (t <br />1 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 />O <br />m <br />N <br />DEPARTMENT LISE ONLY GJ <br />Application Accepted By 11 Date C/' Area / (� �1 Employee ID# D14- <br />Grout Inspection By 4 A Date -1 SPECIAL Well Permit <br />Pump Inspection By Date -1 WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />EyIEI VEa <br />C 0 3 2021 <br />JOAUUIN COUNI Y <br />'VIRONMENTAL <br />t1t �PARTMLNI <br />PE <br />Codes <br />SC Received <br />Info <br />Ch Amount a Permit/Invoice # Well ID# <br />sh Remitted Service Re uest # <br />Yi <br />o� <br />y � <br />FT�- <br />EHD 63-06 6111/2019 6 / / 12—'7 <br />2—'7 i ,j -V WELL /PUMP PERMIT <br />