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N <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE -STOCKTON CA 95205 -6232 (209) 468-3420 <br />NUN•KEFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />JOBADDRESS 37.42 N Beecher Ed CITY/ZIP,StOCktO�95215 <br />CROSS STREET Fa i rt -h i 1 f7 Rd APNO R 91 R () O 3 PARCEL SIZE <br />8 8,9 LAND USE APPLICATION # Z <br />OWNER NAME i r_hc1-C] Relt:Sl c' -i l.ler PHONE <br />OWNER ADDRESS 3792 N Reecher Rcj CRYISTATE/ZIP,St Qck On,CA 95215 <br />CONTRACTOR Purviance Drillers, INC PHONE 209-887-3554 <br />CONTRACTOR ADDRESS P - 0- BOX 64 CITY/STATFZPLinden CA 95236 <br />SUBCONTRACTORICONSULTANT <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />LICENSE X C-57 = C-61 D-09 <br />BILLING PARTY: ❑ OWNER <br />Other <br />-.CONTRACTOR <br />CITY/STATE/ZIP- <br />NUMBER 377923 <br />SUBCONTRACTOR/CONSULTANT <br />PHONE <br />ExPIRATION DATE 7/31/23 <br />DOMESTIC WELL SAMPLING: C General Mineral/Coliform Bacteria (4391) C DibromochlorooroDane (4392) F Arsenic (4393) <br />NTENDED USE \,/Domestic/Private - Irrigation/Agricultural I Industrial = Water Quality Monitoring"i Soil Sampling/Characlenza6on <br />C Public Water System <br />If different from Owner Water System Name Contact Name or Phone Number <br />TYPE OF WORK C New Well i- Replacement Well Well Alteration/Modification -. Other <br />= Monitoring Well(s) # of wells - Soil Boring(s) z of borings -. Geotechnical Y of borings <br />-- Out -Of -Service Well Out -Of -Service Well Renewal D Cross -Connection Repair <br />New Pum Pump Replacement XPump Repair G Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method = Mud Rotary Air Rotary Auger Cable Tool - Push Point U Other <br />Proposed Well Depth ft Excavation in diameter Open Bottom C 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 Plastic - Stainless Steel .. I Other <br />Grout Seal Depth ft I Neat Cement (94 lb bag/5-70 gal wafer) Sand Cement sack mix/7 gal water <br />J Bentonite (20% solids) D Other <br />Grout Placement Method _! Pumped ... Free Fall ,2 Other - Retardant / Accelerator (name) <br />PEDESTAL Installed By - Driller Pump Contractor L Other <br />Concrete Pedestal --Dimensions: Width ft Length ft Thick in Christy Box .I Stove Pipe <br />PUMP "Submersible.i Turbine '- Other HP Pump Set l Oi It Standing Water Level �t 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 />°o <br />m <br />N <br />Application Accepted By �L L Date Area Ci Employee ID# <br />Grout Inspection By Dat SPECIAL WBII Permit <br />Pump Inspection By <br />r ^ -1 WAIVEF ieceived <br />- S � `��% �! _ <br />Soil Boring Ins ection By _ ate Constructed Well Depth ft <br />COMMENTS %teL'C,2 c,t✓ 1 SA •/ CL►�1 '''� <br />PE <br />Codes <br />SC Received Check#! Amount DatePermit/ Invoice # Well ID# <br />Info By_ Cash Remitted S rvice Re u st # <br />'43i'a <br />EHD43-06 8/11/2019 WELL /PUMP PERMIT <br />cF%E <br />1 VF6 <br />24 ?421 <br />J/N C'00 <br />ARTMENT <br />