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• <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNT' ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAzrLTON AVENUE -STOCKTON CA 95205 -6232 (209) 4683420 <br />1y VIY-RCYUNUAtl Lt YEKMff www.sigov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />JOBADDREss 9484 N Jacktone gd CITY/Z`2t-oGktetqCA 95212 <br />CROSS STREET P j,Cjh t Mile R d APN 0 6 5 0 7 0 3 4 PARCEL size 4. 7 2] LAND USE APPLICATION # <br />dtU <br />OWNERNAME Bob Caemar <br />nri 'S`�.PHONE <br />OWNERADDRESS 13881 Eiaht Milo Rrl CITY/STATE/ZIPLinden,CA 95276 <br />CONTRACTOR Purviance Drillers, INC PHONE209-887-3554 <br />CONTRACTOR ADDRESS P . 0• BOX 64 CITYISTATEMPL i nden CA 95236 <br />SUBCONTRACTOR/CONSULTANT PHONE <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />LICENSE X C-57 _ C-61 - D-09 Other_ <br />BILLING PARTY: = OWNER CONTRACTOR <br />CITYISTATE/ZIP_ <br />NUMBER 377923 <br />SUBCONTRACTOR/CONSULTANT <br />EXPIRATION DATE 7/ 3 1/ 2 1 <br />DOMESTIC WELL SAMPLING: f General Mineral/Coliform Bacteria (4391) 7 Dibromochloropropane (4392) L Arsenic (4393) <br />INTENDED UBEomestic/Private Irrigation/Agricultural ._ IndustrialWater Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />If different from Owner Water System Name Contact Name or Phone Number <br />TYPE OF WORK New Well Replacement Well Well AlteratiorVModification Other <br />MonitoringWell(s) #of wells __SoilBoring(s) Cofborings Geotechnical of borings <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />New Pum *ump Replacement - Pump Repair _ Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method Mud Rotary Air Rotary Auger _ Cable Tool Push Point 7 Other RA Nr <br />Proposed Well Depth It Excavation in diameter I Open Bottom ❑ Gravel Pack/Gravel Size in d"[ <br />Conductor Casing in diameter I Conductor Casing Depth ft HEA LT <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Schad Steel ! PlaSOC Stainless Steel i' Other <br />Grout Seal Depth ft _ Neat Cement (94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br />__ Bentonite (20% solids) 3 Other <br />Grout Placement Method - Pumped Free Fall I., Other Retardant / Accelerator (name) <br />(PEDESTAL Installed By = Driller Pump Contractor L Other <br />Concrete Pedestal GDimensions: Width It Length ft Thick in rl Christy Box Stove Pipe <br />POMP 4ubmersibleG Turbine Other HP Pump Set ft Standing Water Level <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. 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 />E <br />DEPARTMENT USE ONLY /� 1 <br />Application Accepted By !y Date �! Area LFZI Employee ID# <br />Grout Inspection By Date ) SPECIAL Well Permit <br />Pump Inspection By t Date :1 WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />EI ENT <br />QED <br />G 2 4 2011 <br />)E�COUNTY <br />L <br />MENT <br />PE <br />Codes <br />L13ei <br />SC Received Check#( Amount Date Per nit/ Invoice # Well ID# <br />Info ash Remitted i e uest# <br />J 'o <br />EHD a3 -0B 6t11i2019 ^ <br />WELL (PUMP PERMIT <br />