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s <br /> WELL/'PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232 (209)468-3420 <br /> NON-REFUNDABLE PERMIT 7 Www.s ov.of /ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> LnL <br /> JOB ADDRESS / L l�zTf'YYlQrI jjio (Nem CITY/ZIP Ln>e4 7S� �6 m <br /> CROSS STREET `/ ��'e men S APN C5-31 bG%144 PARCEL SIZE �y ? LAND USE APPLICATION# rn <br /> v <br /> OWNER NAME J7�![/Uvc {V p/ItPHONE y ��`f ��Z3 7� vi <br /> OWNER ADDRESS _ p�USS� /C�G /mow �� CITY/STATE/ZIP ✓ ,,n' <br /> CONTRACTOR Purviance Drillers, INC PHONE209-887-3554 <br /> CONTRACTOR ADDRESS P-O- BOX 64 CITYISTATE/ZIPL i nde n CA 95236 <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTORICONSULTANT 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 CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391)❑ Dibromochloropropane(4392)I Arsenic(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 ew Well Replacement Well ❑ Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells Soil Boring(s) #of borings Geotechnical #of borings <br /> Out-Of-Service Well � Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> _ New Pump Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method kMud Rotary Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depth 5j-D ft Excavation es in diameter Y Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing,fir, in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter/& inThickness/Gauge/ASTM Sched a��� XSteel E Plastic Stainless Steel , Other <br /> Grout Seal Depth 61%;0-0/—) ft Neat Cement(941b bag/5-10 gal water) 'Sand Cement /O, �' sack mix/7 gal water <br /> - Bentonite(20%solids) J Other <br /> Grout Placement Method I/Pumped -- Free Fall i Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller _ Pump Contractor } Other <br /> Concrete Pedestal . Dimensions:Width batt ft Thick l i in Chris�B, 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 L S. <br /> -tUV ANGE NOTiC::E REQUIRED FOR ONS - PLEASE CALL(20-4) 953-7697 <br /> SIGNE TITLEC,azz'C r A– DATE(/2—2-- .�2,,D <br /> I <br /> (� 1 <br /> N <br /> 1 S <br /> Q <br /> l v� <br /> DEPARTMENT USE ONLY �J <br /> Application Accepted By ��v� Date la Jd vdJ Area �l 7G1 Employee ID# DA <br /> Grout Inspection By Date `�( �O L�2 \ -1 SPECIAL Well Permit <br /> Pump Inspection By Date l WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS Wes} 1,4 AFIO OS319,J/5 30ss0 Ketijc-,7Qo 1k,k7e. /W(tl►lic"o f-oat setback - roro cc;n�1 <br /> L fec S mak\ <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cash Remitted Service Re uest# <br /> �i3��1 I i SeL 4 91)0 <br /> ? 4� <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />