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r _ <br />WELUPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 6232 (209) 4683420 <br />NON-REFUNDABLE PERMIT WWW.s oV.or /ehd EXPIRES i YEAR FROM DATE ISSUED <br />JOBADORESS 1 21 1 N Dietrich Rd cRYj]jp Linden, CA 95236 <br />CROSSSTREET Milton RD APN 10521006 PARCEL Siq-56.3 <br />'LAND USE APPLICATION # <br />OWNERNAME Johnson Fami 1 ,r Part- <br />PHONE <br />OWNERADDRESS 730 N Di at -r; rh Rd CITY/STATEIMP_Linden i,CA95236- <br />CONTRACTOR Purviance Drillers INC <br />PHONE209-887-3554 <br />CONTRACTOR ADDRESS P.O. BOX 64 Cm/STATEIZIPLindetl CA 95236 <br />SUBCONTRACTORICONSULTANT <br />PHONE <br />SUBCONTRAcTOR/CONSULTANT ADDRESS CITYISTATEZP <br />LICENSE k C-57 -1 C-61 i' D-09 :; Other NUMBER 3779237/31 /23 <br />EXPIRATION DATE <br />BILLING PARTY: OWNER L CONTRACTOR L SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: t' General Mineral/Coliform Bacteria (4391) o Dibromochloropropane (4392) D Arsenic (4393) <br />INTENDED USE !' Domest C/Private-flrrigation/Agricultural C Industrial L. Water Quality Monitoring I I Soil Sampling/Characterization <br />Public Water System <br />If different from Owner. Water System Name <br />Conrad Name or Phone Number <br />TYPE OF WORK i New Well C Replacement Well C Well Aiteration/Modification % Other <br />Monitoring Weli(s) #ofwelis C Soil BOring(s) Aofbodngs ❑ Geotechnical Cof borings <br />Out -Of -Service Well C Out -Of -Service Well Renewal D Crass -Connection Repair <br />_. Nww Primp D....... D.....___-__. _ . - . <br />Drilling Method Mud Rotary Air Rotary L Auger _ Cable Tool Push Point C Other <br />Proposed Well Depth ft Excavation in diameter 11 Open Bottom D Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in ThicknesslGaugelASTM Sched <br />Steel C Plastic _I Stainless Steel A Other <br />Grout Seal Depth ( ft Neat Cement (94 Ib bag/5.10 gal water) C Sand Cement- <br />-- solids) D Other sack mixf7 gal water <br />Grout Placement Method D Pumped _ Free Fall D Other C Retardant / Accelerator (name) <br />PEDESTAL Imtalled By C Driller _Pump Contractor ❑ Other <br />Concrete Pedestal "'Dimensions: Width ft Length ft Thick <br />n Christy Box [= Stove Pipe <br />PUMP -; Submersible Turbine Other <br />HP Pump Set ft Standing Water Level 1 ft <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WfTH SAN <br />COUNTY <br />CURRENT <br />ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND <br />RKACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br />WOERS COMPENSATION LAWS. <br />PLFASE CALL (2.09) 953- 617 <br />SIGNED�`�(ii,{.Zriy,.�.� <br />-� —K r MtN I U5E ONLY <br />Application Accepted By �=�/l Date J E Area / employee ID# <br />Em to <br />Grout Inspection By _ 1 Date I I SPECIAL Well Permit <br />Pump Inspection By ti� �f�Z, Z <br />Date � ] WAIVER Received <br />Soil Boring Inspection By Date <br />COMMENTS Constructed Well Depth ft <br />SC Received Check#! IP�Amount Permit/ <br />info B ash Remitted Date Invoice # Well ID# <br />^ SeMce Reqauest# <br />l7 .�- V I / a.1a ♦ r . . , . T_TA---Sr�rn <br />EHD 43.06 6l1112019 <br />/W, <br />�/-3-37 —1 I <br />WELL !PUMP PERMR <br />WED <br />2021 Ep <br />2021 <br />COUNT <br />NTA Y <br />'TMENT <br />