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WELL/PL PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />NON-REFUNDABLE PERMIT Www.sjg org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />JOBADDREss 3507 N Duncan Rd CITY/ZIP1.;nr9anrCA 95236 <br />CROSS STREET Tnha c - CO Rd APN i n S n g n 1 4 PARCEL SIZE1 1 1, 9LkND USE APPLIC TIO <br />� 1 <br />OWNERNAMEWi111am & Grace Machado Family LP PHONE 7� J '� <br />OWNERADDRESS P Q Rn3c SSS CITY/STATE/ZIPLin den,Ca 95236 <br />CONTRACTOR Purviance Drillers, INC PHONE209-887-3554 <br />CONTRACTOR ADDRESS P. 0- BOX 64 Cnv/STATE21PL i nd en CA 95236 <br />SUBCONTRACTORICONSULTANT <br />PHONE <br />SUBCONTRACTORICONSULTANT ADDRESS CITYISTATEIZIP <br />LICENSE%C-57 = G-61 D-09 _ Other NUMBER 377923 EXPIRATION <br />BILLING PARTY: --. OWNER C CONTRACTOR ('. SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) L Dibromochloropropane (4392) n Arsenic (4393) <br />7/31/23 <br />FN 1 eNueu use uomesuclrnvate ImgatiOn/Agncultural ' Industrial C Water Quality Monitoring n Soil Sampling/Characterization <br />Public Water Syst m <br />If different from Omer. Water system Name Contact Name or Phone Number <br />TYPE OF WORK E New Well 1. Replacement Well Well AlterationlModification ; Other <br />MonitoringWell(s) #of wells "Soil Bonng(S) :or borings Geotechnical ttorborings <br />A Out -Of -Service Well Out -Of --Service Well Renewal _ Crass -Connection Repair <br />C New Pump 'Pump Replacement Pump Repair i. Raise Well Casion <br />Drilling Method '" Mud Rotary Air Rotary ❑Auger -- Cable Tool iJ Push Point Other E <br />✓o <br />Proposed Well Depth ft Excavation in diameter n Open Bottom - Gravel Pack/Gravel Size n art? r I <br />Conductor Casing in diameter I Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Schad 1 Steel E Plastic C Stainless Steel I Other <br />Grout Seal Depth ft Neat Cement (94 Ib bag/S-10 gal water) C Sand Cement sack mixR gal water <br />Bentonite (20% solids) C Other <br />Grout Placement Method Pumped = Free Fall li Other Retardant / Accelerator (name) <br />(PEDESTAL Installed By ' Driller = Pump Contractor C Other <br />Concrete Pedestal--: Dimensions: Width ft Length ft Thick in Christy Box C Stove Pipe <br />PUMP XTurbine . Other HP _L C 2 Pump Set -�_ ft Standing Water Level \Li _------OV— <br />Submersibleft <br />I HEREBY CERTIFY THAT I NAVE 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 COMPI IANCF Wrru At r <br />DEPARTMENT USE ONLY <br />Application Accepted By Date G' • ' I Area ` 1 �t� Employee ID# ffi <br />Grout Inspection By Date :] SPECIAL Well Permit <br />Pump Inspection By r .i s'7 Date? 1 -1 WAIVER Received <br />Soil Boring In on By _ Date onS" oted Well Depth ft <br />COMMENTS J, � ! �JJ ) .) ii 'y/ i1i ), ( t <br />c <br />PE <br />Codes <br />SC I Received Check#1 Amount Permit/ <br />Info Am, as Remitted Dat Service Request # Invoice # Well ID# <br />3f�1 <br />0. 0_ _ yl :Mug <br />I <br />EHD43-06 aivans <br />WELL /PUMP PERMIT <br />