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WELUPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468.3420 <br />IYyI`I-KEFUNDABLE PERMIT www.sigov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />JOBADDRESS 22921 E Mari pOsa Rn CITY2IP ESCdlon,CA 95320 <br />CROSS STREET Dodds RD APN 20717001 PARCEL SIZE1 0 0. 7 LAND USE APPLICATION # <br />OWNERNAME Dove Price 'n.52- _PHONE Ck� LQ '3 <br />OWNERADDRESS 21657 P. Dadds Rd C-/STATE/ZIP EScalon,CA 95320 <br />CONTRACTOR Purviance Drillers, INC PHONE209-887-3554 <br />CONTRACTOR ADDRESS P- 0- BOX 64 _ CmYISTATEIZIPL i nden CA 95236 <br />.TANT <br />SUBCONTRACTORICONSULTANT ADDRESS <br />LICENSE X C-57 C-61 'I D-09 i_' Other <br />BILLING PARTY: Li OWNER I] CONTRACTOR <br />PHONE <br />CITY/STATEMP <br />NUMBER 377923 EXPIRATION <br />C SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: C General Mineral/Coliform Bacteria (4391) t! Dibromochloropropane (4392) C Arsenic (4393) <br />7/31/23 <br />INTENDED USE - DomesticJPrivate XIrrigation/Agricultural Li Industrial ; Water Quality Monitoring I1 Soil Sampling/Characterization <br />D Public Water System <br />If different from Ovmer. Water System Name Contact Nama or Phone Number <br />u rvew even L- meplacemeni Well Well Alteration/MOOttication ',i Other <br />D Monitoring Well(s) # of wells C Soil Boring(s) z of borings n Geotechnical # of borings <br />C Out -Of -Service Well C Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />(Drilling Method :- Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom C 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 r. Plastic Li Stainless Steel ! Other <br />Grout Seal Depth ft 7 Neat Cement (94 Ib bag/S-10 gal water) Sand Cement sack MW7 gal water <br />Bentonite (20% solids) ❑ Other <br />Grout Placement Method Pumped : i Free Fall G Other _ Retardant / Accelerator (name) <br />PEDESTAL Installed By _ Driller = Pump Contractor C Other <br />Concrete Pedestal Dimensions: Width ft Length ft Thick in Christy Box C Stove Pipe <br />PUMP 7 Submersible',(Turbine 7 Other HP 2) Pump Set —I' ft Standing Water Level ft <br />I HEREBY CERTIFY THAT 1 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 />y DEPARTMENT U E ONLY t <br />Application Accepted By �� 1_ �— Date %'� J'/� / Area L C Employee ID# A C7 <br />Grout Inspection By Date .1 SPECIAL Well Permit <br />Pump Inspection By Date -1 WAIVER Received <br />Soil Boring Insrpecti BXX Date 7— Constructed Well Depth ft <br />COMMENTS 13t C <br />PE SC IReceived Check#/ Amount Date PermW <br />Codes Info ash Remitted Invoice # Well IDA <br />$t n Re # <br />43Fi L oso ,5A 1 T 77 117--A *1A it7f41Y I <br />EH043-06 6111M019 <br />WELL /PUMP PERMIT <br />Ln <br />m <br />13 <br />0 <br />N <br />