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w <br />I SAN JOAgUINCOUNTY ENVIRONMENTAL HEALTH DEPARTWELUPUMP PERMIT <br />1868 EAST HAZELTON AVENUE - $TOCKTON CA 95205 <br />NON-REFUNDABLE PERMIT W. <br />-6232 (209) 468-3420 <br />WtNjgoy.ol g/ehd EXPIRES 1 YEAR FROM DATE <br />JOBDD <br />ARESS 5098 N Jacktone RD _ ISSUED <br />CROSS STREET Tully Rd <br />CITY21P.Lider1 <br />n CA <br />95236 <br />APN ng, nannA <br />OWNER NAME <br />PARCEL SIZE 4 0 <br />LAND USE APPLir.T f! <br />Dn G GO na Partenership <br />- f- ieldr Q <br />.. A <br />OWNER ADDRESS _13.797 F Fanning Rd <br />f <br />PHONE <br />�1 <br />CONTRACTOR Purviance Drillers INC <br />CITY/STATEZIP_Stnrkton-CA <br />95215 <br />PHONE209-887-3554 <br />CONTRACTOR ADDRESS P-0• Box 64 <br />CRY/STATE/ZIPLinden CA <br />95236 <br />PHONE <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />Cny/STATEIZIP <br />LICENSE $ C-57 C-61 D-09 Other NUMBER 377923 7/31/23 <br />EXPIRATION DATE <br />BILLING PARTY; OWNER ;: CONTRACTOR <br />_ :_. SUBCONTRACTORICONSut TeNr <br />DOMESTIC WELL SAMPLING: L General Mineral/Coliform Bacteria (4391)''7 Dibromochloropropane (4392) ❑ Arsenic (4393) <br />INrENDeD U5E Domestic/Priva[e nigation/Agricultural 'Industrial Water Qualty Monitoring C Soil Sampling/Charade ization <br />Public Water Syst <br />If differem from Owner Water System Name <br />Co^tact Name or Phone Number <br />TYPE OF WORK New Well Replacement Well ❑ Well Afteration/Modification <br />Other <br />Monitoring Well(s) # of wells ❑ Soil Boring(s)# of borings <br />Out -Of -Service Well Geotechnicaf of borings <br />L' Out -Of -Service Well Renewal Cross -Connection Repair <br />New Pump Replacement Zf Pump Repair <br />WELL CONSTRUCTION i� Raise Well Casin <br />Drilling Method : Mud Rotary Air Rotary Auger Cable Tool Push Point Other 1�7NVI <br />Proposed Well Depth ft Excavation in diameter D Open Bottom E Gravel Pack/Gravel Size <br />Conductor Casing in diameter / Conductor Casing Depth ft in diamet <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched <br />Grout Seal Depth _ Steel Plastic Stainless Steel r i Other <br />P ft :; Neat Cement (94 lb bag/5-90 gal water) :: Sand Cement <br />Bentonite (20% solids) D Other sack mixi7 gal water <br />Grout Placement Method -; Pumped _= Free Fall L Other <br />rEDESTAL Installed By Driller C Pump Contractor G Other <br />(; Concrete PedestalDimenslons- Width ft Length ft Thick <br />in Christy Box Stove Pipe <br />Pump <br />Submersiblej Turbine Ll Other HP /o2S <br />Pump Set �� ft Standing Water Level Jam;, 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. 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 />--• —11 - mC N I USt N L Y / <br />Application Accepted By — ':L Z-- Date . % it <br />Area Employee lD# /1" <br />— <br />Grout Inspection By Date <br />Pump Inspection By SPECIAL Well Permit <br />Date <br />Soil Boring Inspection By Date WAIVER Received <br />COMMENTS Constructed Well Depth ft <br />,13�' Zi <br />Date ­rrrnv <br />( Service Request # Invoice # Well ID# <br />EHD 43-06 Blt 1!2019 a V� <br />I WELL /PUMP PERM1IIT <br />rrr <br />Im <br />D <br />°o <br />�n <br />N <br />