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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 />1 NON-REFUNDABLE PERMIT WWW.sigov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 95 6 8T CITY/ZIP yCyr•ki-r'tTt, CA 95215 <br />CROSS STREET Baker Rd APN Q S 9 0t) Q 5 Q PARCEL SIZE <br />3_LAND USE APPLICATION # <br />OWNER NAME V &A T, qO r i n <br />OWNERADDRESS1 nF?S $ comstock Rd <br />CONTRACTOR Purviance Drillers, INC <br />CONTRACTOR ADDRESS P.O. BOX 64 <br />SUBCONTRACTORICONSULTANT <br />PHONE <br />ClY/STATE/ZIPrjr,c3an,CA 95236 <br />PHONE 20 9 - 8 8 7 - 3 5 5 4 <br />CITY/STATE21PL i n d e n CA 95236 <br />PHONE <br />SUBCONTRACTOR/CONSULTANT ADDRESS CITYISTATEZP <br />LICENSE C-57 i C-61 L D-09 Ll Other NUMBER 7/31 <br />X 377923 EXPIRATION DATE / 2 3 <br />BILLING PARTY: :.; OWNER f3 CONTRACTOR ; SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: fl General Mineral/COlifOrm Bacteria (4391) :7 Dibromochloroorooane (43921 i ! Arsenic (414at <br />NTENDED USE ❑ Domestic/Private Irrigation/AgricuRural :: Industrial �: Water Quality Monitoring Soil Sampling/Characterization <br />D Public Water System <br />N different from Owner. Water System Name Contact Name or Phone Number <br />- - --- - -- •---•• ••�• .- .c,iccc— rvc '.: -un H era➢Onir000mcanon -: utner <br />D Monitoring Well(s) # of wells : Soil Bonng(s) a Or borings ; Geotechnical # or borings <br />D Out -Of -Service Well Out -Of -Service Well Renewal ; ] Cross -Connection Repair <br />D New Pump Y Pump Replacement 7 Pump Repair 71 Raise Well Casino <br />Drilling Method _: Mud Rotary 1 Air Rotary Auger 7 Cable Tool . Push Point .7 Other <br />Proposed Well Depth ft Excavation in diameter n Open Bottom L Gravel PacklGravet Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Schad Steel :: Plastic :1 Stainless Steel "I Other <br />Grout Seal Depth ft Neat Cement (94 Ib bag/5-10 gal water) Sand Cement sack mix/7 gal water <br />Bentonite (20k solids) Ei Other <br />Grout Placement Method _: Pumped ❑ Free Fall ❑ Other ;; Retardant / Accelerator (name) <br />PEDESTAL Installed By _ Driller CC Pump Contractor L Other <br />Concrete Pedestal ;'Dimensions- Width ft Length ft Thick in -' Christy Box " Stove Pipe <br />PUMP Submersible Turbine L Other HP Ci Pump Sete ft Standing Water Level ( ft <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 I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATIoMr AwS <br />1f�'?t'F f'tiF I!!f t �^ 'a; ± r I -t a c/ r.s n. r''',.! <br />TITLE 0�"�"t't� CL lMJ! DATE gld"t <br />rn <br />m <br />D <br />v <br />z <br />N <br />■■■■■■■■■■■■■■■■■■�nommmmmm mom MEN <br />i■■■:%■■ONE ME. . <br />■■■■■■■■■■■■■■E■■.■■MEN ■■rr!■■■■mom ■■■■■■■ <br />■■■■■■■■■■■■■■= 0 ■Mi■■■■■ONE ■■■■■■■ <br />■■■■■■■■■■■■■PAP ■■■■■■N.C�►:1■■�■■■■■W■■■■■■■r <br />■.■.■.........■.......«�■....■■.�.■...■■■■h <br />. <br />........................■■..■.■ ON ME M. <br />■■■■■■■■,lSi! ■■■■■■■■■■■■V■■■■■■■■■■■■■■■■ Wis • • <br />■■■■ mom ■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■ iiL�i' • • <br />PE <br />Codes <br />SC Received Check#/ Amount Permit/ <br />Info ash Remitted j Dat Sery ce RequestRequest# Invoice # Well ID# <br />6��V ---F <br />13tz zs13- WELL /PUMP PERMIT <br />