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r j <br />'WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL <br />HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />NON-REFUNDABLE PERMIT <br />WWW,S OV.Of /ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />12425 E com sok <br />Rd <br />C -/Zip Linden CA 95236 <br />Beecher RD APNO8916003 <br />FCR <br />ip <br />m <br />PARCEL 91zE 3 2 . 0 GLAND USE APPLICATION <br />v <br /># <br />jq <br />O <br />PHONE <br />SS –29-8-b 1�1 T?PP(`}1PT <br />ur <br />CITYISTATE/T.jP <br />CONTRACTOR Purviance Drillers, INC Starkton,CA 95215 <br />PHONE209-887-3554 <br />CONTRACTOR ADDRESS P•O• BOX 64 <br />CIN/STATEMP Linden CA 95236 <br />SUBCONTRACTOR/CONSULTANT <br />SUBCONTRACTOR/CONSULTANT ADDRESS PRONE <br />CrTY/STATE/ZIP <br />LICENSE C-57 _< C-61 _i D-09 :_ Other NUMBER 377923 ExPrRATION DATE 7/31/2-3 <br />BILLING PARTY: <br />: ; OWNER ::: CONTRACTOR SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: 1.: General Mineral/Coliform Bacteria (4391) .7 Dibromochloropropane <br />(4392)1. Arsenic (4393) <br />INTENDED USE Domestic/Private ^ Irrigation/Agricultural "i Industrial <br />Water Quality Monitoring :; Soil SamplinglCharacte zation <br />Public Water System <br />If difrorsnt from Owner" Water System Name <br />Contact Name <br />TYPE OF WORK or Phone Number <br />New Well i - Replacement Well 1' Well Alteration/ModifiCation <br />Monitoring Well($) # of wells her <br />--'Soil Boring(s) # of bo Other <br />Out-Of-Service Well -:Geotechnical_ #of borings <br />Out -Of -Service Well Renewal Cross -Connection Repair <br />New Pum ' <br />um Re lacement 1: Pum2 Repair <br />WELL CONSTRUCTION - Raise Well CaSin <br />Drilling Method :_ Mud Rotary Air Rotary 1, Auger Cable Tool Push Point " Other <br />Proposed Well Depth ft ExcavationG in diameter -I Open Bottom <br />P <br />Gravel Pack/Gravel Size <br />;,Conductor Casing in diameter / Conductor Casing Depth in diameter <br />REQ MFNT <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched ft <br />Steel ;: Plastic ;Stainless Steel J Other <br />Grout Seal Depth ft Neat <br />�' 1 i <br />�/ £. /1 <br />Cement (94/b ba915.10 al water <br />9 ) Sand Cement <br />iBentonite (20% solids) J Other sack mrx/7 gal water <br />C�/� <br />S <br />Grout Placement Method _, Pumped ❑ Free Fall L Other <br />[[//�_ � U c <br />-. Retardant /Accelerator (name) .S Q <br />PEDESTAL Installed By _1 Drifter L Pump Contractor L Other <br />Concrete Pedestal <br />?0�� <br />v/N <br />^Dimensions: Width ft Len <br />Length ft Thick in i ; Christy <br />VIRC)CO <br />UN <br />Box :' Stove Pipe <br />PUMP ubmersible,I Turbine -: Other HP Pump Set <br />H DFpgRTM Z Ty <br />ft Standing Water Level Ift <br />I HEREBY CER FY THAT I HAVE PREP ARED THIS APPLICATION <br />ENT <br />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 <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS <br />LICENSE IS <br />STATE LICENSEBOARD AND THAT 1 AM IN COMpt jam, <br />WORKERS COMPENSATION LAWS. . ., . <br />r� <br />/ --1MK I MtN T USE ONLY <br />Application Accepted By _ 1=�%�G. / / <br />Date /�' Area i EmployeeID# /)- r <br />Grout Inspection By Date , <br />J SPECIAL Well Permit <br />Pump Inspection By r` Date t <br />1 WAIVER Received <br />Soil Boring Inspection By Date <br />COMMENTS Constructed Well Depth ft <br />SC <br />Invoice # <br />Well ID# <br />EHD 43-p8 6/112019 <br />WELL !PUMP PERMR <br />