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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL <br />HEALTH DEPARTMENT 1668 EAST HAZELTON AVENUE - STOCKTON CA 95205 <br />NON-REFUNDABLE PERMIT .6232 (2119) 468-3420 <br />WWW.S OV.Or/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />ADDRESS 13909 St Rt <br />Hwy26 <br />CITY/ZIPUnden CA 95236 <br />FCROSSSTREET,Tacktone Rd <br />0 <br />m <br />APN.0g105023 PARCEL SIZE 3 <br />4 4 • 8LAND USE APPLICATION # <br />ERNAME <br />O <br />Brj t tal la VenturesER <br />ADDRESS �` BOX 1 7O PHONE <br />y <br />N <br />CITY/STATE/ZIP T,i nden CA 95236 <br />CONTRACTOR Purviance Drillers INC <br />CONTRACTOR ADDRESS P. O. BOX 64 PHONE209-887-3554 <br />c"JSTATPJZIPLinden CA 95236 <br />SUBCONTRACTOR/CONSULTANT <br />SUBCONTRACTOR/CONSULTANT ADDRESS PHONE <br />CtrY1STATE/ZIP <br />LICENSE X C-57 :_ C-61 : D-09 -.; Other NUMBER 377923 EXPIRATION DATE 7/31 /23 <br />BILLING PARTY; <br />- OWNER ;.CONTRACTOR L SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: L General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) f! Arsenic <br />INTENDED <br />(4393) <br />USE `Sc Domestic/Private Irrigation/Agncultural : Industrial <br />7. Water Quality Monitorin <br />Public Water System 9 : Soil SampungiCharactenzation <br />If different from ov er Water System Name <br />Contact Name or Phone Number <br />TYPE OF WORK _ New Well 1 : Replacement Well -7 Well Alteration/Modification <br />: Other <br />Monitoring Well(S) # Of wells '" Soil Borings) # orbonngs <br />Y/�jE • , <br />Out-OfService Well =: Geotechnical #of borings <br />Out-OfService Well Renewal <br />New Pum um Replacement Cross -Connection Repair <br />. Pum Re <br />'V <br />air <br />WELL CONSTRUCTIONCasing <br />=Raise Well Casin <br />Y D <br />Drilling Method C: Mud Rotary . Air Rotary [ Auger :: Cable Tool :. Push Point <br />Proposed Well De th - Other <br />P ft Excavation in diameter -1 Open Bottom _-. Gravel Pack/Gravel Size <br />Conductor Casing in diameter / Conductor Casing Depth ft N_ L (R� <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched <br />Grout Seal De th Steel Plastic Stainless Steel I Other N <br />P ft Neat Cement (94 /b ba9/5-10 gal water) Sand Cement <br />Bentonite (20% solids) _j Other sack mix/? gal water <br />Grout Placement Method I Pumped C Free Fall C Other <br />Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller L Pump Contractor L Other <br />Concrete Pedestal ':Dimensions: Width ft Len th <br />9 ft Thick in _: Christy Box i? Stove Pipe <br />PIMP Submersible:: Turbine _] Other Hp I I - <br />Pump Set ft Standing Water Level III JA 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. <br />176202, <br />EIV 0j- <br />,4 <br />CNTy <br />FNT <br />/ .+=riafc I m t N l USE ONLY <br />Application Accepted By �'� G �� ( t,'f - <br />Date ur I Area Employee ID# 1 i <br />Grout Inspection By mate <br />-.1 SPECIAL Well Permit <br />Pump Inspection By I ! Date —`? L �!— <br />WAIVER R2C01Ved <br />Soil Boring Inspection By Date <br />COMMENTS Constructed Well Depth ft <br />EH04306 6/11/2019 <br />�f 13/73870 <br />Invoice # <br />Well ID# <br />WELL /PUMP PERMIT <br />