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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAzELToN AvENuE - STOCKTON CA 95205 -6232 (209) 4683420 <br />NUN-KEFUNDABLE PERMIT www.sjgov.cirgiena EXPIRES 1 YEAR FROM DATE ISSUED <br />JoB ADDRESS A D1lnran Rn -77 to lD, Cm21PT,;nr3anr(A 952361 <br />CROSS STREET Tobacco Rd I.PN (��� II %�r„�PARCEL SIZE • 48 LAND USE APPLICATION# [� 1 <br />OWNER NAME Paul Vaccarezza PHONE <br />OWNER ADDRESS 77()0 N Diincan RD CITY/STATEIZIPLinden, r'A 957161 <br />CONTRACTOR Purviance Drillers, INC PHONE209-887-3554 <br />CONTRACTOR ADDRESS P - 0. Box 64 CITY/STATEMPL i nd en CA 95236 <br />TANT <br />PHONE <br />SUBCONTRACTORICONSULTANT ADDRESS CnY/STATE/2AP <br />LICENSE C-57 ❑ C-61 D-09 Other NUMBER 377923 EXPIRATION DATE 7/31/23 <br />BILLING PARTY: OWNER CONTRACTOR G SUSCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: 17 General Mineral/Coliform Bacteria (4391) ! Dibromochloropropane (4392) C Arsenic (4393) <br />NTENDED USE * Domestic/Private L: Irrigation/Agricultural ; Industrial Water Quality Monitoring U Soil Sampling/Charactenzation <br />Public Water System <br />If different from Owner. Water System Name Contact Name or Phone Numt)er <br />TYPE OF WORK New Well i : Replacement Well - Well Alteration/Modification D Other <br />Monitoring Wells) # of wells Soil Boring(s) # of borings t7 Geotechnical # of borings <br />Out -Of -Service Well Out -Of -Service Well Renewal t! Cross -Connection Repair <br />New Pump ; Pump Replacement N(Pump Repair _- Raise Well Casing <br />Drilling Method -! Mud Rotary -1 Air Rotary i ; Auger :! Cable Tool „ Push Point 1. Other <br />Proposed Well Depth ft Excavation in diameter n Open Bottom F Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched n Steel C Plastic n Stainless Steel '1.I Other <br />Grout Seal Depth ft .i Neat Cement (94 lb bag15-10 gal water) C Sand Cement sack mix/7 gal water <br />U Bentonite (20% solids) D Other <br />Grout Placement Method Pumped - Free Fall ti Other Retardant / Accelerator (name) <br />PEDESTAL Installed By G Driller _ Pump Contractor L Other <br />Concrete Pedestal '_Dimensions: Width ft Length ft Thick in 7, Christy Box ❑ Stove Pipe <br />PUMP . Submersible Turbine 11 Other HP Z Pump Set ) It 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 WIT E CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPE SA�10� <br />...Ai ANH77: "d -!'ICF_ RE(ILr1.^70 FOR "R - PLEASE CALL f299N 95?_''cr•. <br />SIGNED TrTLE COnJ'V014 1 DATE 41 Z- , al <br />Application Accepted By �� <br />C�Li�/ <br />DEPARTMENT USE <br />Date � S- <br />ONLY �f {�!� <br />' ' Area 1 Employee ID# � J 5 - <br />Grout Inspection By <br />Pump Inspection By77 <br />i I SPECIAL Well Permit <br />zrr n WAIVER Received <br />Date 1 <br />Soil Boring Inspection By <br />COMMENTS .L F%'%'00, 117 <br />Date <br />Constructed Well De th ft <br />CX' �F: SSS "-V Y-jj+ 7F/1/ M7f-' Well I'S <br />ate` 1�-Cl <br />^ <br />`I1P PIC- ir_ A G/1i <br />rn <br />m <br />D <br />mm <br />4 <br />YMENT <br />CEIVED <br />27207.1 <br />QUIN COUNTY, <br />ONMENTAL <br />DEPARTMEN3 <br />UM�166'&2FMftVM=�i►i'� <br />EHD 43-08 01!2019 <br />EHD 43-08 01!2019 <br />