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• <br />r WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAml-TON AVENUE - STOCKTON CA 95205.6232 (209) 4683420 <br />NUN-KEFUNDABLE PERMIT www.sigov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />Joe ADDRESS 1118 Ava19A Dr Crn'IZIPStncki-nnXA 9521S <br />CROSS STREET W h i t- p T. n APN ] n l l 9 n n d PARCEL SIZE 1 93 LAND USE APPLICATION # <br />OWNER NAME TnThn CLzpr <br />PHONE <br />OWNER ADDRESS _ 1 1 1 8 Ilirgl nn Dr CnrrYlSTATElZIPRj7nr`ktnn ',(A 95215 <br />CONTRACTOR Purviance Drillers, INC PHONE209-887-3554 <br />CONTRACTOR ADDRESS P- 0- BOX 64 CITY/STATE¢IPLi nden CA 95236 <br />SUBCONTRACTORICONSULTANT PHONE <br />SU13CONTRACTOPJCONSULTANT ADDRESS CITY/STATE/ZIP <br />LICENSE k C-57 C-61 1 D-09 Other NUMBER 377923 EXPIRATION DATE 7/ 31 / 21 <br />BILLING PARTY: OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: C General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) 17 Arsenic (4393) <br />NTENDED USE Domestic/Private ii Irrigation/Agricultural .. 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 />I YPE OF 1NORK .: New Well 1' Replacement Well i1 Well Alteration/Modification F Other <br />Monitoring Well(s) # of wells D Soil Boring(s) # of borings Geotechnical # of borings <br />Out -Of -Service �Well u Out -Of -Service Well Renewal C Cross -Connection Repair <br />New Pump L JPUMD Replacement ❑ Pumn Rennir r Rnicu won r .i— <br />Drilling Method ' : Mud Rotary : Air Rotary Auger Cable Tool f I Push Point �] Other <br />Proposed Well Depth ft Excavation in diameter a 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 i i Steel Plastic '! Stainless Steel ;1 Other <br />Grout Seal Depth ft -: Neat Cement (94 lb bag/5-10 gal water) _7 Sand Cement sack mix/7 gal water <br />C Bentonite (20% solids) U Other <br />Grout Placement Method -' Pumped _- Free Fall L Other Retardant / Accelerator (name) <br />PEDESTAL Installed By _ Driller :: Pump Contractor L Other <br />C Concrete Pedestal _Dimensions: Width ft Length ft Thick in L Christy Box ^ Stove Pipe <br />PUMP <br />YI-Submersible- Turbine I: Other HP Pump Set_tn-ft Standing Water Level 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 />SIGNED\\c .L(�t-�.s-ar-cc,, TITLE4�y/✓IG�laG.. <br />r <br />DATE <br />/ DEPARTMENT USE rONLY <br />Application Accepted By �L -L Date 7 �3 Area �/ ` Employee ID# <br />Grout Inspection By Date U SPECIAL Well Permit <br />Pump Inspection By Date 3 WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />to <br />m <br />D <br />0 <br />4E YMFN <br />CE6 /V� <br />?6 4?021 <br />O v�N C <br />pqR AL <br />PE <br />SC Received Check#/ <br />Info B ash <br />Amount Date <br />Remitted <br />Permit/Codes Invoice # Well ID# <br />Service Request # <br />s <br />L"D <br />47 <br />, <br />1 1 <br />�....��, W•"�u� � <br />7�47 7 WEU. /PUMP PERMIT <br />�' <br />