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WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232 (209)468-3420 <br /> NON-REFUNDABLE PERMIT www.sigov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 19812 Gawne Rd CITYlZIP 1/ Zp,�eFvx m <br /> ,f <br /> CROSS STREET S. 4A) A I1 c4i APN 195' 000 z PARCEL SIZE 4 LAND USE APPLICATION# p <br /> A <br /> rn <br /> OWNER NAME Lance Top lnl PHONE 209-531 -7879 y <br /> OWNER ADDRESS PO BOX 1229 CITY/STATE21P Ripon, CA 95336 <br /> CONTRACTOR Purviance Drillers, INC PHONE209-867-3554 <br /> CONTRACTOR ADDRESS P.O. BOX 64 CITY/STATE/ZIPL i nden CA 95236 <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP <br /> LICENSE X C-57 C-61 D-09 Other NUMBER 377923 EXPIRATION DATE 7/31 /21 <br /> BILLING PARTY: OWNER 7 CONTRACTOR SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING: I_General Mineral/Coliform Bacteria(4391)❑ Dibromochloropropane(4392)CArsenic(4393) <br /> INTENDED USE _ Domestic/Private ** Irrigation/Agricultural Industrial ❑ Water Quality Monitoring 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 Replacement Well Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells Soil Boring(s) #of borings = Geotechnical <br /> Out-Of-Service Well Out-Of-Service Well Renewal L Cross-Connection Repair <br /> New Pum Pum Replacement Pum Repair Raise Well Casingr <br /> WELL CONSTRUCTION OAQ(J <br /> Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other HEATH�AtAI__ <br /> IL <br /> Proposed Well Depth 5 ft Excavation 22 in diameter Open Bottom Gravel Pack/Gravel Size ut:PARrM�a tem er <br /> _. Conductor Casing�L�in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter /� in Thickness/Gauge/ASTM Sched ,45.15 )(Steel Plastic I! Stainless Steel _j Other <br /> Grout Seal Depth 100 -*/— ft Neat Cement(94 Ib bag/5-10 gal water) Sand Cement !c. 3 sack mixl7 gal water <br /> _ Bentonite(20%solids) _i Other <br /> Grout Placement Method X Pumped Free Fall L: Other Retardant/Accelerator(name) <br /> PEDESTAL In talled By Driller _ Pump Contractor— L Other <br /> Concrete Pedestal Dimensions:Width `, ft Lengt ft Thick in 7 Christy Box - Stove Pipe <br /> PUMP Submersible . Turbine - Other HP Pump Set ft 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 WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. �`�{t+g� /� �+ re <br /> .n�trsr n,f:,.+w 1 IUG REL,R�I�.."_rte. .,-........, ..r...7PE1✓TI®!'-1.^. '0A?R? <br /> .�A .. .. <br /> SIGNED TITLE Corporate Secretary <br /> DATE /�j f(,12 <br /> -- — ..— <br /> r-A O <br /> e <br /> b Y00 <br /> I <br /> DE ARTMENT USE ONLY <br /> Application Accepted By '/ Date Area Employee ID# �6►'�'-' <br /> Grout Inspection By Date `1 5 `7n 2\ PEC AL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth 0 <br /> COMMENTS <br /> PE SC Received heck#A Amount Permit/ <br /> Info Date Remitted Service Request# invoice# Well ID# <br /> lQ' <br /> EHD 43.06 6/11/2019 <br /> WELL/PUMP PERMIT <br />