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I <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205.6232 (209) 468-3420 <br />.1— oma--....... .m ' v n I.hri FXPIRFS 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 10401 E Comstock Rd CITY2IP Stockton,CA 95215 , <br />CROSS STREET St Rt Hwy 88 APN 08905014 PARCEL SIZE - 13 LAND USE APPLICATION # <br />r <br />OWNER NAME E1 17ahPth Brnwn PHONE 1 <br />OWNERADDRESS 10401 E Comstock Rd CITY/STATE/ZIPStockton,CA 95215 <br />CONTRACTOR Purviance Drillers, INC PHONE209-887-3554 <br />CONTRACTOR ADDRESS P.O. Box 64 _ CITY/STATE/ZIPL i nden CA 95236 <br />! <br />SUBCONTRACTORICONSULTANT PHONE <br />SUBCONTRACTOR/CONSULTANT ADDRESS CITYISTATEIZIP <br />LICENSE X C-57 7 C-61 D-09 _. Other NUMBER 377923 EXPIRATION DATE 7/31 /23 <br />BILLING PARTY: _ OWNER ..CONTRACTOR - SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: C General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) ❑ Arsenic (4393) <br />INTENDED USE 1, Domestic/Private Irrigation/Agricultural C Industrial = Water Quality Monitoring _1 Sail Sampling/Characterization <br />- Public Water System <br />If different from Ovmer Water System Name Contact Name or Phone Number <br />TYPE OF WORK New Well Replacement Well C Well Alteration/Modification Other <br />Monitoring Well(s) # of wells C Soil Boring(s) K of bonngs - Geotechnical t of borings <br />Out -Of -Service Well C Out -Of -Service Well Renewal . Cross -Connection Repair <br />New Pum _ := Pump Replacement V Pump Repair Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method ❑ Mud Rotary Air Rotary , Auger _ Cable Tool Push Point Other <br />iProposed Well Depth ft Excavation in diameter Open Bottom f: Gravel Pack/Gravel Size <br />DConductor Casing indiameter / Conductor Casing Depth ft(iEgLTH O <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Schad Steel - Plastic C Stainless Steel .1 Other � <br />Grout Seal Depth ft = Neat Cement (94 lb bag/5-10 gal water) Sand Cement sack mix/7 gal water <br />D Bentonite (20% solids)) Other I <br />Grout Placement Method Pumped .. Free Fall I_' Other Retardant / Accelerator (name) <br />iPEDESTgL Installed By Duller _ Pump Contractor _ Other <br />- Concrete Pedestal -Dimensions: Width ft Length ft Thick in _ Christy Box - Stove Pipe <br />PUMP Submersible Turbine Other HP Pump Set t 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 COJPENSAT1011/(�WS. <br />DEPARTMENT USE ONLY <br />Application Accepted By 2-4 / -"L Date r Area < < Employee ID#_4 <br />Grout Inspection By <br />–� Date I SPECIAL Well Permit <br />Pump Inspection By 7/- Date Z _j WAIVER Received <br />Soil Boring IJ� ee%tion By Date Constructed Well Depth it <br />COMMENTS l <br />FANT <br />FO <br />14 ?021 <br />ttv <br />ENTA NTy <br />4RTMENT <br />PE <br />Codes <br />SC Received Check#/ Amount Permit/ <br />Info B 4ash Remitted Dateil Service Request # Invoice # Well ID# <br />EHD 43-06 6/112019 � WELL /PUMP PERMIT <br />