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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 />JOBADDRESS 1 8207 Baker Rd <br />CROSSSTREET Duncan Rd <br />www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUES <br />CITY/ZIP Linden, CA 95236 <br />APN 09124028 PARCEL SIZL2 3. 3 9 LAND USE APPLICATION # <br />OWNER NAME Albert Croce Ranch PHONE <br />OWNERADDRESS P.O. Box 40 Cm/STATE2IP_Linden. CA 95236 <br />CONTRACTOR Purviance Drillers, INC PHONE209-887-3554 <br />CONTRACTOR ADDRESS P - 0 - Box 64 CITY/STATE/ZIPL i nd e n CA 95236 <br />SUBCONTRACTOR/CONSULTANT <br />SUBCONTRACTORICONSULTANT ADDRESS <br />LICENSE k C-57 I C-61 D-09 9 Other <br />BILLING PARTY: OWNER " CONTRACTOR <br />CITY/STATEMP_ <br />NUMBER 377923 <br />0 SUBCONTRACTOR/CONSULTANT <br />PHONE <br />EXPIRATION DATE 7/ 3 1 / 2 1 <br />DOMESTIC WELL SAMPLING: F, General Mineral/Coliform Bacteria (4391) C Dibromochloropropane (4392) 11 Arsenic (4393) <br />INTENDED USE Domestic/Private 'Irrigation/Agricultural C Industrial Water Quality Monitoring '11 Soil Sampling/Characterization <br />Public Water Syste <br />If different from Owner: Water System Name Contact Name or Prone Number <br />t Tre U� VVURK new well i Keplacement Well 13 Well Alteration/Modification C Other <br />Monitoring Well(s) of wells C. Soil Boring(s) aof borings Geotechnical xofbodngs <br />Out -Of -Service Well I I Out -Of -Service Well Renewal G Cross -Connection Repair <br />7 New Pump_ Pump Replacement ❑ Pump Repair ❑ Raise Well Casino <br />Drilling Method ; Mud Rotary Air Rotary [ Auger _^• Cable Tool Push Point - Other <br />Proposed Well Depth ft Excavation in diameter t Open Bottom ❑ Gravel Pack/Gravei Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched " Steel ❑ Plastic n Stainless Steel ' I Other <br />Grout Seal Depth ft Neat Cement (941b bagl5-10 gal water) 11 Sand Cement sack mixf7 gal water <br />Bentonite (20% solids) i] Other <br />Grout Placement Method Pumped _ Free Fall 11 Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor L Other <br />Concrete Pedestal CDimensions: Width ft Length ft Thick in Christy Box t 1 Stove Pipe <br />PUMP Submersible 1- Turbine :. Other HP Pump Set \0 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. I 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 />PLEASE CALL (209)953__.. _.. <br />SIGNED s�^L �•��1L iG�iL4sf3it•-� TITLE DATE &/Z.7fZI <br />DEPARTMENT USENLY <br />Application Accepted By L- Date ir. ��. / Area Employee ID# ✓ r <br />Grout Inspection By r Data .1 SPECIAL Well Permit <br />Pump Inspection By Date v 3 7 WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />T <br />m <br />D <br />0 <br />A <br />m <br />N <br />D <br />20?1 <br />pg FlV 0 rY <br />R T MENT <br />PE <br />Codes <br />SC Received Check#/ Amount Date Permit/ Invoice # Well ID# <br />Info sh Remitted service Re nest # <br />enu a;Wy tin t/2019 <br />/275-7943' WELL /PUMP PERMIT <br />