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WELL/PUMP PERMIT <br />• SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />PERMIT <br />DATE <br />ADDRESS 4a14 Fine Rd Cry/LPTrrr�„ri-n, CA 05236 <br />SS STREET FI r)nr1 R(] APN n g 3 p 7 C1 2 PARCEL SIZE 1 - 4 LAND USE APPLICATION # <br />IERNAME JdmPS A iarrnrin TIVC' '� I�t4.�1.'Y�A' % Kt'/t,'.it LikOT)� PHONE <br />IER ADDRESS _1rj 5 N PI.121C3nRCj CITYISTATE/ZIP_Ilr3Pn r ('A <br />TRACTOR Purviance Drillers. INC PHONE209-887-3554 <br />TRACTOR ADDRESS P- 0- BOX 64 CITY/STATE(ZIPL i nden CA 95236 <br />kr C-57 <br />PARTY: <br />PHONE <br />.TANT ADDRESS CITY/STATFJZIP ) <br />C-61 G D-09 ; Other NUMBER 377923 EXPIRATION DATE 7 3 1 23 <br />._:OWNER ::CONTRACTOR SUBCONTRACTOR(CONSULTANT <br />DOMESTIC WELL SAMPLING: G General Mineral]Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE DomeStiC(Private ❑ Irrigation/Agnrultural I1 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 />T rc yr vventn __ New even I Keplacement Well :: Well Alteration/Modification i,. Other <br />MonitoringWeil(s) #of wells CSoilBoring(s) kotborings Geotechnical 0ofborings <br />G Out -Of -Service Well Out -Of -Service Well Renewal i_: Cross -Connection Repair <br />7 New Pump Pump Replacement "AilumD Repair C Raise Well Casino <br />Drilling Method := Mud Rotary t. Air Rotary , ; Auger Cable Tool i : Push Point L Other <br />Proposed Well Depth ft Excavation in diameter 1] Open Bottom tl Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Weil Casing Diameter _ in Thickness/Gauge/ASTM Schad SteelG Plastic Stainless Steel ;I Other <br />Grout Seal Depth ft C Neat Cement (94 Ib bagl5-10 gal water) G Sand Cement sack mix(T gal water <br />Bentonite (20% solids) ❑ Other <br />Grout Placement Method Pumped Free Fall C Other Retardant / Accelerator (name) <br />PEDESTAL Installed By ' Driller '_ Pump Contractor G Other <br />_: Concrete Pedestal _Dimensions: Width ft Length ft Thick in it Christy Box ❑ Stove Pipe <br />PUMPSubmersible- Turbine ;]Other HPC_ Pump Set QT,% It Standing Water Level \t In R <br />I HEREBY CER FY 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 />T <br />D <br />a <br />z <br />N <br />yy DEPARTMENT USE ONLY <br />Application Accepted By ��-�L� Date � / Area q /`% Employee ID# ��i <br />Grout Inspection By 11 SPECIAL Well Permit <br />Pump Inspection By ` L (� ❑ WAIVER Received <br />Soil Boring Inspection By Data Constructed Well Depth ft <br />COMMENTS <br />PE SC Recely d <br />Codes Info <br />heck#/ Amount <br />ash Remitted D to <br />Permit/Invoice # WL -11 ID# <br />Service Re uest# <br />e7a� <br />- 2 <br />I <br />EHD 43-06 6/11/2019 / l /� / <br />I v "v/ (/ 2,v L) WELL/PUMP PERMIT <br />WENT <br />:EIVED <br />03 2021 <br />,OWN COUNTY <br />IONMENTAL <br />[S±RTMENI <br />