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DATE /52 -1/ —2i SIGNED <br />TIT1 <br />LI AV <br />-3 <br />Ct.1 <br />kto-I CAD <br />..MMInkr <br />DEPARTMENT USE ONLY <br /> <br />Application Accepted By <br /> <br />Grout Inspection By <br />Pump Inspection By Ay\---../L_ <br /> <br />Soil Boring Inspection By <br />COMMENTS ,Aie 1,4 wet 1„,-,1 PO 0 qd 0,7„17- <br />pf-3 Mel ifs"cicalle,t1V (=in ,1 pt eriis" rk) <br />Date <br />Date <br />Date <br />Date <br />Area 4//q4 Employee ID# F6 <br />D SPECIAL Well Permit <br />ICAtt4t--( U WAIVER Received <br />Constructed Well Depth ft oi di/ bye/4 Aks td: sem ef <br />, WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - SrociocN CA 95205 -6232 (209)468-3420 <br />NON-REFUNDABLE jrvIrr WWW.S ov.or ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />r/ <br />JOB ADDRESS 800 0 n.Podesta Ln CrraZio Linden, CA 95236 Lo <br />rr <br />CROSS STREET St Rt Hwy 26 APN 091 3 5 0 27 PARCEL SIZE 3 . 0 LAND USE APPIJCATION # C <br />OWNER NAME porl pc i- a 1:tr-clq PHONE i <br />OWNER ADDRESS 8000 Podesta Ln crrWsTATErim Linden , CA 95236 <br />CONTRACTOR Purviance Drillers, INC pH0NE 209-887 —3554 <br />CONTRACTOR ADDRESS P . 0 . Box 64 crryisTATE/zipL i n d en CA 9 5 2 3 6 <br />SUBCONTRACTOR/CONSULTANT PHONE <br />SUBCONTRACTOR/CONSULTANT ADDRESS GEN/STATE/Zip <br />LICENSE RC-57 0C-61 :I 0-09 i] Other NUMBER 377923 EXPIRATION DATE 7/31/23 <br />BILLJNG PARTY: : OWNER : CONTRACTOR ;.] SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: E General Mineral/Coliform Bacteria (4391) 0 Dibromochloropropane (4392) 0 Arsenic (4393) <br />INTENDED USE -Domestic/Private 0 irrigatIon/Agricultural 0 Industrial 0 Water Quality Monitoring G Soil Sampling/Characterization <br />Public Water System <br />If different from Owner Water System Name Contact Name or Phone Number P TYPE OF WORK I:: New Well 0 Replacement Well 0 Well Alteration/Modification 0 Other .1 <br />=I Monitoring Well(s) # of wells C Soil Boring(s) s of borings 0 Geotechnical it of borings <br />0 Out-Of-Service Well 0 Out-Of-Service Well Renewal 0 Cross-Connection Repair <br />New Pump i: Pump Replacement 0 Pump Repair 0 Raise Well Casing X <br />WELL CONSTRUC 0 ee 7 <br />Drilling Method 0 Mud Rotary 0 Air Rotary 0 Auger E Cable Tool E7, Push Point 3 Other 84N <br />Proposed Well Depth ft Excavation in diameter U Open Bottom 0 Gravel Pack/Gravel Size ing Q <br />0 Conductor Casing in diameter / Conductor Casing Depth ft <br />N,...4 0 , <br />1.. A rt., <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched I] Steel 0 Plastic 0 Stainless Steel cl Other Ot; <br />Grout Seal Depth ft [.] Neat Cement (94 lb bag/5-10 gal water) U Sand Cement sack mix/7 gal water <br />0 Bentonite (20% solids) 0 Other <br />Grout Placement Method 0 Pumped 0 Free Fall n Other 0 Retardant / Accelerator (name) <br />Pei_Aeia- Installed By 3 Driller 0 Pump Contractor C Other <br />ii Concrete Pedestal EDimensions: Width ft Length ft Thick in 11 Christy Box 0 Stove Pipe <br />i/ PUMP ?Submersible 3 Turbine 0 Other HP 2.- Pump Set ,-1 ft Standing Water Level \ 40 ft <br />I HEREBY CER FY THAT I HAVE PREPARED THIS APPUCATION 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 />---,VI/ANC7 tICYrir.:7. rF.r!!!2'.7.7..172 FCP 71,1SPEirTMIS - PLF:isSE CALL (209) 9F?-7F97 <br />PE <br />Codes <br />SC <br />Into <br />Received ChecIdti <br />cash <br />Amount <br />Remitted Date, Permit/ <br />Service Request # Invoice # Well ID# <br />L-13gC,4 0 ,Y1 J.2-J.2-V (na,__ .6 - d #1 10 11-111-1 We(M...)4(1 1 <br />END 43-06 6/11/2019 /33 l2;5-6.93 <br /> WELL /PUMP PERMIT