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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 />NUN-KEFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES i YEAR FROM DATE IssUEE <br />Jos ADDRESS 1141 N F3PPrher Rd CITY21PStockton,CA 95215 <br />CROSSSTREET _FinkhohnPr rid APN. 1031 6040 PARCELSIZE8.97 LAND USE APPLICATION# <br />OWNERNAME Jnhn Armaninn <br />PHONE <br />OwNERADDRESS 1271 N Beecher Rd crry/STATE/zlPStockton,CA 95215 <br />CONTRACTOR Purviance Drillers, INC PHONE209-BB7-3554 <br />CONTRACTOR ADDRESS P - O- BOX 64 Cm/STATE/ZIPL i nde n CA 95236 <br />LICENSE k C-57 <br />BILLING PARTY: <br />.TANT ADDRESS <br />.11 C-61 G D-09 <br />OWNER <br />CITY/STATE/ZIP <br />i.: Other NUMBER 377923 <br />CONTRACTOR 7 SUBCONTRACTOR/CONSULTANT <br />PHONE <br />EXPIRATION DATE 7/31/23 <br />DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) [: Dibromochloropropane (4392) IJ Arsenic (4393) <br />NTENDED USE `SC\DOmeSUC/Private ;i Irrigation/Agricultural C Industrial ,7 Water Quaiity Monftoring []Soil Sampling/Characterization <br />/::Public Water System <br />If different from Owner. Water System Name Contact Name or Phone Number <br />., •�•• ••�a ncNmoement vveii � Well A¢eramon/modlmCahon ;] Uther <br />D Monitoring Well(s) # of wells 2 Soil Bodng(s) # of borings -i Geotechnical It of bonngs <br />J Out -Of -Service Well ❑ Out -Of -Service Well Renewal ! Cross -Connection Repair <br />D New Pump `y{Pump Replacement J Pump Repair ❑ Raise Well Casino <br />Drilling Method r Mud Rotary L: Air Rotary D Auger U Cable Tool C Push Point C Other <br />Proposed Well Depth ft Excavation in diameter 11 Open Bottom 0 Gravel Pack/Gravel Size In diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched C Steel ❑ Plastic I I Stainless Steel J Other <br />Grout Seal Depth ft [ 1 Neat Cement (941b bag/5-10 gal water) Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) ❑ Other <br />Grout Placement Method ,I Pumped C Free Fall 0 Other I7 Retardant / Accelerator (name) <br />PEDESTAL Installed By _ Driller L Pump Contractor C Other <br />G Concrete Pedestal ^Dimenslons: Width It Length ft Thick in Christy Box i7 Stove Pipe <br />PUMP 'Submersible= Turbine ; Other HP Pump Set 1 (r,SL a StandingWater Level r �� 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 />1 A r &, sr, <br />''' pay-+`�J'�//j ;_I" Pd:'l???".1�+;���1! 5 �� I"`.:.fF/.�I11��tc.�'s"(G'�-�I,-,��.:.c," <br />SIGNED�'Z�^"^1----/ TITLE OKiu�Llc. DATE <br />DEPARTMENT USE ONLY 1 <br />Application Accepted By _ `'' L- Date / I �� .� 0 Area q `/ Employee ID# MS <br />Grout Inspection Byl SPECIAL Well Permit <br />Pump inspection By 27 %ate ) Z i ❑ WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />_0 <br />D <br />O <br />m <br />PAYMENT <br />RECEIVED <br />NOV 17 2021 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH OEPARTMENI <br />PE SC Received <br />Codes Info I AEbd 7 <br />Checlt#/ <br />sh <br />Amount Permit/ <br />Remitted Date Service Re nest # Invoice # Well ID# <br />F7 <br />Sal. <br />-77 Z <br />I <br />�.................. I <br />r <br />4-._� - ";tr 1 9 I 10 0 7 /--47 1— 11 1 1 j ( Ld ZI WELLIPUMPPERMIT <br />