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19 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMWELUPUMP PERMIT <br />1868 EAST HAZELTON AVENUE <br />NON-REFUNDABLE PERMIT -STOCKTON CA 95205 -6232 (209) 4683420 <br />WwW.s' ov.or lehd EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 1 5 � 1 7 Harney Ln <br />CITY21P 1.nr9i _CA 95740 <br />OWNER NAMEPl <br />CROSS STREETjj T71l l �r Rri APNO5309009 <br />PARCEL SIZE 1—OB—LAND USE APPLICATION # <br />' ' I j <br />I ) , a1 % 'j, <br />PHONE ?. l; <br />OWNERADDRESS 1 5777 E Harney Ln - <br />CONTRACTOR Purviance Drillers, INC CITYISTATFJZIP_Lod i CA 95240 <br />CONTRACTOR ADDRESS <br />P - O. Box 64 PHONE209-887-3554 <br />arwsTATEOpLinden CA 95236 <br />SUBCONTRACTOR/CONSULTANT <br />SUBCONTRACTORJCONSULTANTADDRE5S PHONE <br />CITYISTATE/Z1P <br />LICENSE X C-57 C-61 D-09 Other <br />NUMBER 377923 EXPIRATION DATE 7_ �31 �23 <br />BILLING PARTY; is OWNER <br />.:CONTRACTOR _: SUBCONTRACTOR/CONSULT A <br />NT <br />DOMESTIC WELL SAMPLING: L General Mineral/Coliform Bacteria 4391 <br />INTENDED USE Domestic/Private i7 Imgation/Agricultural -: Industrial ) ^ Wlater OuaOtD Montionn a (4392) Ll Arsenic (h - <br />Public Water System y 9 Soil Sampling/Cha acterizat on <br />If diHerant I— Owner. Water System Neme <br />Contact Name cr Phone Number <br />TYPE OF WORK . Now Well f; Replacement Well <br />L Well AlterdtionfModification :: Other <br />Monitoring Well(s) # of wells C Soil Boring(s) #or borings <br />Out -0f -Service Well Geotechnical #ofbonngs <br />Out -Of -Service Well Renewal L Cross -Connection Repair <br />New Pum L Pum Re lacement <br />WELL CONSTRUCTION Pump Repair Raise Well Casing <br />Drilling Method [ Mud Rotary 7 Air Rotary Auger Cable Tool ' Push Point <br />Proposed Well Depth ft Excavation o Other <br />in diameter ❑Open Bottom _� Gravel Pack/Gravel Size <br />Conductor Casing in diameter / Conductor Casing Depth in diameter <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Schad ft <br />Grout Seal Depth ft _ Steel ; ; Plastic Stainless Steel :1 Other <br />Neat Cement (9416 bag/5_10 gal water) Sand Cement <br />Bentonite (20% solids) -1 Other sack MW7 gal water <br />Grout Placement Method Pumped � Free Fall I: Other <br />--`_ ; : Retardant/Accelerator (nam <br />Installed By L Driller C mp PuContractor L Other e) <br />is Concrete Pedestal Dimensions: Width ft Len th <br />9 ft Thick in 1- Christy Box -_ Stove pipe <br />ubmersible:7 Turbine Other+ <br />HP -i Pump Set 1 r ft Standing Water Level _ I, g <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 1 AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSAT`ON LAIVS. <br />PLEASE I': <br />1� TtTLE . V,(1 W DL @t}O( <br />DATE 9S <br />DEPARTMENT USE ONLY <br />Application Accepted By � L L Date r7 �� � ; LI yy! <br />Area 91 Employee ID# /+, <br />Grout Inspection By Date <br />�-. -- SPECIAL Well Permit <br />Pump Inspection By ii Date WAIVER Received (,. L <br />Soil Boring Inspection By <br />COMMENTS Date Constructed Well Depth ft <br />PE <br />�O <br />Date <br />EHD 43-06 6/11.2019 Ce -4 <br />1 3 a 6 a s l 3 Sl <br />Invoice # I Well ID# <br />Lc,2j WELL IPUh1P PERMIT <br />m <br />M <br />D <br />0 <br />0 <br />M <br />ti <br />RECEIVEDp <br />AUG 2 7 2021 <br />SAN JOAQUIN COUNTY, <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />