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3r � <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1668 EAST HAZELTON AVENUE-STOCKTON CA 95205 -6232 (209) 468-3420 <br />IVUI`I-KEFUNDABLE PERMIT WWW.S Ov.cr lend CAYIi I TEAK FKUM DATE ISSUED <br />JOB ADDRESS 10900 N Clements RD CITYIZIPr,inr]en XA 95236 <br />CROSS STREET F ra i 7 P r R r1 APN 06519015 PARCEL SIZE1 . 8 5 LAND USE APPLICATION # <br />OWNER NAMEt <br />'],'hnmac and T,inr3a nnimPtt PHONE <br />OWNERADDRESS 10900 N Clements CITY/STATE21P Linden,CA 95236 <br />CONTRACTOR Purviance Drillers, INC PHONE209-887-3554 <br />CONTRACTOR ADDRESS P . D . BOX 64 CITY/STATE/ZIPL i nden CA 95236 <br />SU13CONTRACTORICONSULTANT <br />PHONE <br />SUBCONTRACTORICONSULTANT ADDRESS CITYISTATE/ZIP <br />LICENSE R C-57 - C-61 C. D-09 Other NUMBER 377923 EXPIRATION DATE 7/31/23 <br />BILLING PARTY: OWNER C CONTRACTOR ,:i SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: i. General Mineral/Coliform Bacteria (4391) G Dibromochloropropane (4392) C Arsenic (4393) <br />NTENDED USE Domestic/Private [5 Irrigation/Agricultural C Industrial D Water Quality Monitoring C: Soil Sampling/Characterization <br />Public Water System <br />If different from Owner Water System Name Contact Name or Phone Number <br />TYPE OF WORK 12 New Well Replacement Well ]l Well Alteration/Modification Other <br />MonitoringWell(s) #of wells 0SoilBoring(s) mofborings �;�Geotechnical of borings <br />Out -Of -Service Well 0 Out -Of -Service Well Renewal _ Cross -Connection Repair <br />New Pump VPUmD Replacement a PumD ReDair G Raise Well Casino <br />WELL CONSTRUCTION <br />Drilling Method Mud Rotary 7 Air Rotary Auger Cable Tool Push Point Other <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom - Gravel PackiGravel Size in diameter <br />- Conductor Casing In diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched Steel Plastic 7 Stainless Steel : I Other <br />Grout Seel Depth ft Neat Cement (94 Ib bag/5-10 gal water) Sand Cement sack mix/7 gal water <br />Bentonita(20% solids) 3 Other <br />Grout Placement Method Pumped G Free Fall ❑ Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller E Pump Contractor ❑ Other <br />(-- Concrete Pedestal -_Dimensions: Width ft Length ft Thick in Christy Box ❑ Stove Plpe <br />PUM uhmersible Turbine G: Other HP Pump Set it Standing Water Level e� t) it <br />I HEREBY CERTIFY THAT 1 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 COMPENSATi ON LAWS. <br />SIGNED I - TITLE C O Q (FUf - DATE l D `at <br />DEPARTMENT USE ONLY <br />j 1 / <br />Application Accepted By `-- � ` "��� Date ' � Area q tf Employee ID# -s <br />Grout Inspection By ` D l 1 SPECIAL Well Permit <br />Pump Inspection By f /� �1 J`��j �� _ ate Q WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />PE <br />Codes <br />Sc Received Check#/ Amount Date Permit/Invoice # Well ID# <br />Info B ash Remitted Ice Re uest # <br />38' <br />o, <br />END 43 -OB fi/112078 0I� JO� / WELL !PUMP PERMIT <br />