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WELUPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 -6232 (209) 4683420 <br />N -REFUNDABLE PERMIT www.sigov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />ADDRESS 21049 E St. Rt Hwy 26 CITYIZIPT.iQde, CA 9r,23.6 <br />SS STREET rine Rd APN 1 0 5 2 6 O O A PARCEL SIZE <br />s _ n LAND USE APPIJCATION # <br />OWNERNAMECath)z OT brj nom_ <br />OWNER ADDRESS P. O. BOX 1 3 5 0 <br />CONTRACTOR Purviance Drillers, INC <br />CONTRACTOR ADDRESS P.O. BOX 64 <br />SUBCONTRACTORICONSULTANT <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />LICENSE X C-7 C-61 = D-09 : Other <br />BILLING PARTY: .: OWNER :: CONTRACTOR <br />PHONE <br />CITYISTATE21PLinden, CA 95236 <br />PHONE209-887-3554 <br />CRY/STATE21PLinden CA 95236 <br />CITYISTATE/ZIP- <br />NUMBER 377923 <br />SUBCONTRACTORICONSULTANT <br />PHONE <br />EXPIRATION DATE 7/31 / 21 <br />DOMESTIC WELL SAMPLING: L General Mineral/Coliform Bacteria (4391) C Dibromochloropropane (4392) 1i Arsenic (4393) <br />INTENDED USE omestic/Private :: Irrigation/Agricultural .l Industrial Water Quality Monitoring 0 Soil Sampling/Characterization <br />Public Water System <br />If difierentfrom Own- Water System Name Contac[ Name or Phone Numher <br />i4— —H I meloacement even well Alteration/Modification Other <br />Monitoring Welllsj # of wells Soil Bonn 5 r; or borings y <br />9O e ! Geotechnical #ofborin s <br />Out -Of -Service Well Out -Of -Service Well Renewal = Cross -Connection Repair <br />New Pump )�Rump Replacement Pump Repair 1 Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method - Mud Rotary Air Rotary IAuger Cable Tool ;Push Point Other <br />Proposed Well Depth ft Excavation in diameter l l Open Bottom 'I Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched . 1 Steel :_ Plastic �- Stainless Steel -1 Other <br />Grout Seal Depth ft - Neat Cement (94 lb bag15-10 gal water) f Sand Cement sack mW7 ga r <br />Bentonite (20% solids) D Other E <br />Grout Placement Method _: Pumped Free Fall i : Other-,"qRetardant /Accelerator (name) <br />IPECESTAL Installed By Driller -'Pump Contractor L: Other <br />Concrete Pedestal _:Dimensions: Width ft Length It Thick in f] Christy Box : Stove Pipe <br />PUMPuhmersible77Turbine -I Other HP Pump Set 'm 17) ft Standing Water Levelft <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 LJCFNSF RnArzn nNln Tr I — I.I r•.,.,In, ,,,.,,-r- ....... -. . <br />// DEPARTMENT USE ONLY <br />Application Accepted By _ Z— Date;'/I; d / f' <br />_ Area Employee ID# -DA_ <br />Grout Inspection By Date -1 SPECIAL Well Permit <br />Pump Inspection By r �� Date 7 WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />rn <br />M <br />D <br />°o <br />A <br />m <br />N <br />RE yMENT <br />CE�A/Z 19 V6 <br />yD Ul N 2021 <br />lRppgRTC <br />M,MNr <br />PE <br />Codes <br />Sc Received Check#! Amount Permit/ <br />Info B Cash Remitted ate Service Re ues # Invoice # Well ID# <br />I� <br />1 ' <br />EHD43-06 6/112014 ZI _ <br />/ /It k 1r /,/-0 <br />/ X .(`J ` / /I WELL/PUMP PERMIT <br />