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WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 93205-6232(209)468-3420 <br /> NON-REFUNDABLE PERMIT WWw.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOBADDRE5S 3442 Beecher Rd CITY21PStockton,CA 95215 <br /> CROSS STREET St RT Hwy 26 APN 08918062 PARCEL SIA+01 LAND USE APPLICATION# D <br /> _ O <br /> OWNERNAME DOD Gh ig l l er i <br /> PHONE <br /> OWNERADDRESs 3500 N Beecher Rd CITY/STATHLPStockton,CA 95215 <br /> CONTRACTOR Purviance Drillers, INC PHONE209-887-3554 <br /> CONTRACTOR ADDRESS P-0. BOX 64 CITY/STATE21PL i rid e n CA 95236 <br /> SUBCONTRACTORICONSULTANT PHONE <br /> SUBCONTRACTORICONSULTANT ADDRESS CITY/STATEIZIP <br /> LICENSE k C-57 C-61 17 D-09 Other NUMBER 377923 EXPIRATION DATE 7/3 1/2 1 <br /> BILLING PARTY: :'OWNER !;CONTRACTOR :1 SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING:Ci General Mineral/Coliform Bacteria(4391)-;Dibromochloropropane(4392)U Arsenic(4393) <br /> INTENDED USE emestic/Private 0 Irrigation/Agricultural 0 Industrial Water Quality Monitoring C Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK !.New Well IJ Replacement Well G Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells ❑Soil Boring(s) ik of borings ]Geotechnical Nof borings <br /> Out-Of-Service Weil a Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pum �Pump Replacement Pump Repair D Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary j Auger 7 Cable Tool G Push Point 7 Other <br /> Proposed Well Depth ft Excavation in diameter it Open Bottom 0 Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched -,Steel 0 Plastic ']Stainless Steel I I Other <br /> Grout Seal Depth ft -.-Neat Cement(94 Ib baV5-10 gal water C Sand Cement sack mix/7 gai water <br /> Bentonite(20%solids) D Other <br /> Grout Placement Method .;Pumped _.Free Fall L Other L Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller L'Pump Contractor L Other <br /> Concrete Pedestal!;Dimensions:Width It Length ft Thick in C Christy Box 0 Stove Pipe <br /> PUMP `}%Submersible:'.Turbine =Other HP l -'?- Pump Set ft Standing Water Level ft <br /> I HEREBY CE TIFY THAT 1 HAVE•PREPAIRED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. 1 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 LL Gc TITLE DATE <br /> til � <br /> EC SENT <br /> Y ,3 2021 <br /> �pgFN q�NTY <br /> RTMFNT <br /> A it JL 11 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date S !✓r I Area Aj (/(� I <br /> Employee ID# <br /> Grout Inspection By Date 1 SPECIAL Well Permit <br /> Pump Inspection By � Date -I WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC I Received Check#/ Amount Permit/ <br /> Codes Info Cash Remltted onto Service Re u - Invoice# Well ID# <br /> SCJ -' <br /> 2 C <br /> EMD43-06 8111/2019 /T /2,S—) 7 I ----� WELL[PUMP PERMIT <br />