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WELUPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 4683420 <br />h1f)nl-IlitinAMI C PCD—T ....... ..:..-.. <br />JoBADOREss 3500 N Beecher Rd Ciry/7rPstockton,CA 95215 <br />CROSS STREET S t Rt Hwy 2 6 APN 08918061 PARCEL SIZE1 9, 1 2 LAND USE APPLICATION # <br />OWNERNAME Don Ghiglieri <br />PHONE lit 9, 1� L <br />OWNERADDRESS 3500 N Beecher Rd CITY/STATe21P_Stockton, CA 95215 <br />CONTRACTOR Purviance Drillers, INC PHONE209-887-3554 <br />CONTRACTOR ADDRESS P - 0. Box 64 CITY/STATE21PLinden CA 95236 <br />SUBCONTRACTORICONSULTANT PHONE <br />SUBCONTRACTORICONSULTANT ADDRESS CITY/STATE21P <br />LICENSE iX' C-57 C-61 : i D-09 '.i Other NUMBER 377923 EXPIRATION DATE 7/31/21 <br />BILLING PARTY: OWNERJ CONTRACTOR LJ SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: t; General Mineral/Coliform Bacteria (439 1) 0 i bromo ch loro p ro pa ne (4392) C: Arsenic (4393) <br />INTENDED USEDomestirJPrivate L IrrigatioNAgricultural ': Industrial Water Quality Monitonng Soil Sampling/Characterization <br />Public Water System <br />If different from Owner. Water System Name Cwtact Name or Phone Number <br />TYPE OF WORK New Well C Replacement Well ; Well Alteration/Modification ; Other <br />Monitoring Well(s) #of wefts O Soil Borings) $ofbOf1 gs = Geotechnical If of borings <br />Out -Of -Service Wen D Out -Of -Service Well Renewal ❑ Cross-Connecbon Repair <br />New Pump 7 Pump Replacement Pum Re air ;: Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method �-- Mud Rotary i ; Air Rotary 'i Auger Cable Tool 7. Push Point l Other <br />Proposed Well Depth ft Excavation in diameterI Open Bottom ❑Gravel PacklGravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter_ In Thickness/Gauge/ASTM Schad Steel Plastic '1 Stainless Steel _l Other <br />Grout Seal Depthft 7 Neat Cement (94 Ib bag/5-10 gal water) Sand Cement sack mix17 gal water <br />Bentonite(20%solids) DOther <br />Grout Placement Method _ Pumped - Free Fall I' Other Retardant I Accelerator (name) <br />PEDESTAL Installed By _ Driller -' Pump Contractor L Other <br />Concrete Pedestal '_:Dimensions: Width ft Length ft Thick in C Christy Box 7 Stove Pipe <br />PUMP ubmersible ". Turbin4 : i Other HPPump Set ft Standing Water Level ft <br />c� mw r 111 1.AuvN ANU INAI INt YVVKK 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 COMPENSATION LAWS. <br />))DEPARTMENT USE ONLY <br />Application Accepted By .0 Z— — Date �� O Area Ll �% Employee ID# <br />L <br />Grout Inspection By Date '1 SPECIAL Well Permit <br />Pump Inspection By / Date r� ^� 7 WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />PE SC Received Check#! <br />Codes Info h <br />Amount Date Permit/ <br />Remitted Service Re nest# Invoice # Well ID# <br />3 ,t <br />4 7 Zd 00 <br />FNrl d7 Ac c,,.rn.n <br />/ <br />WELL /PUMP PERMIT <br />