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,r <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1666 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />NUN•KEFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUES <br />JoBADDREss 18917 E Baker Rd CITY/ZIP Linden, CA 95236 <br />CROSSSTREETCOX Rd APN 09124019 PARcELSIZE9.85 LANDUSEAPPLIcAnoN# <br />OWNER NAME MdX COpellO / Rollin RdnCi"t PHONE <br />OWNER ADDRESS _ PC) Rax 562 CnYISTATE/ZIP Linden,CA 95236 <br />CONTRACTOR Purviance Drillers, INC PHONE209-887-3554 <br />CONTRACTOR ADDRESS P - 0. BOX 64 CITY/STATE/ZIPL i nde n CA 95236 <br />SUBCONTRACTOR/CONSULTANT <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />LICENSE k C-57 i] C-61 E D-09 <br />BILLING PARTY: OWNER <br />CITY/STATE/Zip <br />Other NUMBER 377923 <br />[;CONTRACTOR i;; SUBCONTRACTOR/CONSULTANT <br />PHONE <br />EXPIRATION DATE 7/31/23 <br />DOMESTIC WELL SAMPLING: I- General ineral/Coliform Bacteria (4391) C Dibromochloropropane (4392) G Arsenic (4393) <br />'NTENDED USE Domestic/Private rrigation/Agricultural Ci Industrial -] Water Quality Monitoring ❑Soil Sampling/Characterization <br />Public Water System <br />If different from Owner Water System Name Contact Name or Phone Number <br />-- vveii ,; vveii Alrera➢ONMOGnICdtion Other <br />❑ Monitoring Well(s) # of wells Soil Boring(s) : or borings ❑ Geotechnical 9 of borings <br />❑ Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />D New Pum " Pump Replacement Pump Repair Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method :1 Mud Rotary Air Rotary ❑ Auger J Cable Tool t 7 Push Point U Other <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Schad ; Steel I] Plastic ; I Stainless Steel LI Other <br />Grout Seal Depth ft r_ Neat Cement (94 /b bag/5-10 gal water) Sand Cement sack mix/7 gal water <br />❑ Bentonite (20% solids) D Other <br />Grout Placement Method i Pumped C: Free Fall Other Retardant / Accelerator (name) <br />PEDESTAL Installed By :1 Driller L' Pump Contractor L Other <br />Concrete Pedestal EDimensions: Width ft Length It Thick in ;7 Christy Box ❑ Stove Pipe <br />PUMP Submersible_Turbine EOther HP Pump ft Standing Water Level__ (,y�( fl <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 />y <br />m <br />D <br />0 <br />m <br />m <br />H <br />PAYMENT <br />RECEIVED <br />0V 17 2021 <br />AN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />I EALTII DEPARTMENT <br />DEPARTMENT USE ONLY <br />Application Accepted By Date i I /� .R Area CSC, Employee ID#f L 1 <br />Grout Inspection By Date I SPECIAL Well Permit <br />Pump Inspection By 4 ' Date 1 ❑ WAIVER Received <br />Soil Baring Inspection By Date Constructed Well Depth ftCOMMENTS <br />PE <br />Codes <br />Sc eceived <br />Info <br />Check#/ Amount Permit <br />Date Cash Remitted Service Re uest # Invoice # Well ID# <br />-+-77 <br />in Lv' .'t l �'j 4 0 � q I-- 1— 111 Z ) WELL /PUMP PERMIT <br />