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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 www.sjgov.org/ehd EXPIRES i YEAR FROM DATE ISSUED <br />JOB ADDRES37401 COX Rd CrrY/ZIP T.; ndPn, CA 95236 <br />CROs STREET Comstock Rd APN - 09124055 PARCEL SIZE 3 .0 LAND USE APPLICATION III <br />OWNERNAME R.J Cost-gliolo PHONE <br />OWNERADDREsS 7300 N Fine Rd CTIYISTATE2rP T.l'ntj(,n,CA 95236 <br />CONTRACTOR Purviance Drillers, INC PHONE209-887-3554 <br />CONTRACTOR ADDRESS P- 0. BOX 64 CITYISTATEMPL i nd en CA 95236 <br />SuBCONTRACTOR/CONSULTANT PHONE <br />SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP <br />LICENSE R C-57 :: C-61 D-09 Other NUMBER 377923 EXPIRATION DATE 7/ 3 1/ 2 1 <br />BILLING PARTY: , : OWNER 2 CONTRACTOR :] SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: C; General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) i Arsenic (4393) <br />NTENDED USE Domestic/Private Irrigation/Agricuttural Industrial :: Water Quality Monitoring C Soil SamplinglCharacterization <br />Public Water System <br />If different from O—er. Water System Name Contact Name w Ph—a Number <br />TYPE OF WORK = New Well f: Replacement Well C Well AReration/Modification E Other <br />Monitoring Well(s) # of wells ❑ Soil Boring(S) t: of bongs I I Geotechnical N of borings <br />Out -Of -Service Well 1; put -Of -Service Well Renewal [7 Cross -Connection Repair <br />New Pump P Pump Replacement_ {Pump Repair - '' Raise Well Casing <br />Drilling Method - Mud Rotary Air Rotary _ Auger _ Cable Tool i , Push Point Other <br />Proposed Well Depth ft Excavation in diameter : i Open Bottom G Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched i Steel f: Plastic Stainless Steel ; 7 Other <br />Grout Seal Depth ft Neat Cement (941b bag/5-10 gal water) ": Sand Cement sack ma77 gal water <br />- Bentonite (20% solids) C Ofher <br />Grout Placement Method Pumped Free Fall C Other C Retardant / Accelerator (name) <br />PEDESTAL Installed By � Driller - Pump Contractor L Other <br />Concrete Pedestal D -Dimensions: Width ft Length it Thick in Christy Box i] Stove Pipe <br />PUMP C Submersjbl Turbine Other HP Pump Seta N Standing Water Level 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. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />' lyc^ =np����'{{1T.sc <br />SIGN IT_DGZCtA7fGC,. ._ TITLE DATE <br />DATE <br />DEPARTMENT USE ONLY <br />Application Accepted By Z� pate .i p, I Area (1 lr Employee ID# <br />Grout Inspection By 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 />EHD A3 -0B 6/1112019 7,WELL (PUMP PERMIT <br />