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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 />NAN.RFcnuneat c Doee.rr .._.,... _:__-. _­­ <br />-------- --•-• -••- ��r n.w , .—M rnvm LFA It ISA"UED <br />JOB ADDRESS 4607 Archerdale Rd CrrY/zlPLinden,CA 95236 <br />CROSS STREET Oak Ave APN 0 91 1 3 0 3 9 PARCEL SIZE 9 . 9 6 LAND USE APPLICATION # <br />OWNERNAME Charles Cary <br />PHONE <br />OWNERADDRESS 4607 Archerdale Rd Cnv/STATEmp Linden,CA 95236 <br />CONTRACTOR Purviance Drillers, INC PHONE209-887-3554 <br />CONTRACTOR ADDRESS P - O. BOX 64 cln.ISTATEMpLinden CA 95236 <br />SUBCONTRACTOR/CONSULTANT PHONE <br />SUBCONTRACTORICONSULTANT ADDRESS CnY/STATEIZIP <br />LICENSE x C-57 _ C-61 D-09 _= Other NUMBER 377923 EXPIRATION DATE 7/31 / 21 <br />BILLING PARTY: :_{ OWNER - CONTRACTOR G SUBCONTRACTORICONSULTANT <br />DOMESTIC WELL SAMPLING: C General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) ij Arsenic (4393) <br />INTENDED USE Domestic/Private k4rrigabon/Agricultural t] Industrial G Water Quality Monitoring �-! Soil Sampling/Character nation <br />Public Water System <br />e Offerent from Owner. Water System Name Contact Name or Phone Number <br />TYPE OF WORK New Well C Replacement Well _ Well Alterabon/Modiftcation ^ Other <br />:JMonitoring Well(s) #of wells Soil Boring (s) =Of borings ']Geotechnical Cotlforipe _ <br />J Out -Of -Service Well ❑ Out -Of -Service Well Renewal U Cross -Connection Repair 5-`A <br />3 New Pum Pum Replacement G Pum Repair J Raise Well CasingN J� <br />WELL CONSTRUCTION r <br />Drilling Method 7 Mud Rotary i Air Rotary Auger G Cable Tool 7 Push Point Other `ALT <br />Proposed Well Depth ft Excavation in diameter -1 Open Bottom LI Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched 7 Steel G PlasticI j Stainless Steel it Other <br />Grout Seal Depth ft ❑ Neat Cement (94 lb bag15-10 gal water) Sand Cement sack mix17 gal water <br />Bentonite (20% solids) U Other <br />Grout Placement Method C Pumped Li Free Fall L Other a Retardant I Accelerator (name) <br />PEDESTAL Installed By J Driller Pump Contractor E Other <br />C Concrete Pedestal' -'Dimensions: Width ft Length ft Thick in Christy Box Stove Pipe <br />au --P �'Submersihle! ;Turbine ^Other HP i7 Pump Set -'.r It Standing Water Level ft <br />•••-•-�-- ��•-••• cr,1RCv <br />-10 FV'YL11.AIKJN ANu IHAI Int 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 />i vi?Jii71': ;3Uii F> Yx�ICE NO fiCE P,E UIRED FOF G <br />��,yy-lTIONS . PLEASE CALL (?nn? n5,'• -7F9'? <br />SIGNED u.(i4�G.C.� TITLE lA'✓D cJ��%�1 DATE (51-11.2J <br />y� J DEPARTMENT U E ONLY <br />Application Accepted By /� L�� Date b r <br />Grout Inspection By 1 Date ---'° <br />Pump Inspection By - t- Date <br />Soil Boring Inspection By Date <br />COMMENTS <br />Area q r ci Employee ID# �✓ 1 <br />SPECIAL Well Permit <br />,1 WAIVER Received <br />Constructed Well Depth ft <br />PE SC Received Check#/ Amount Permit/ <br />Codes Info Cash Remitted D e Service Request # Invoice # Well ID# <br />-7f'12/ 3,�J-,5�� WELL (PUMP PERMIT <br />N <br />m <br />D <br />a <br />a <br />N <br />yM�)v r <br />CFS V FD <br />�Y 06 ?0?1 <br />QU/N <br />E ,4COUAI <br />RT k <br />