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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAzsLTON AVENUE-STOCKTON CA 95205 -6232 (209) 4683420 <br />NUN-KEFUNDABLE PERMIT www.$)gov.org/ena t_APIKL5 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 23500 E-Cop-peronlis Rd Cm/7rPLinden,CA 95236 <br />CROSS STREET S. Joseph Ln APN 18 7 O 2 ' PARCEL SIzr3 9 --3 9 LAND USE APPLICATION # <br />OWNER NAME R & J Dondero PHONE <br />OWNER ADDRESS 20480 E- Cop_peronolis Rd CITY/STATE/ZIP Linden, CA 95236 <br />CONTRACTOR Purviance Drillers, INC PHONE209-887-3554 <br />CONTRACTOR ADDRESS P- 0- BOX 64 CITY/STATE21PL i nden CA 95236 <br />TANT <br />SUBCONTRACTORICONSULTANT ADDRESS <br />LICENSE ff C-57 ; C-61 ] D-09 <br />BILLING PARTY: OWNER <br />PHONE <br />CrrY/STATE/ZIP <br />Other NUMBER 377923 EXPIRATION DATE 7/31/21 <br />[i CONTRACTOR -1 SUBCONTRACTORICONSULTANT <br />DOMESTIC WELL SAMPLING: C General Mineral/Coliform Bacteria (4391) -i Dibromochloropropane (4392) n Arsenic (4393) <br />INTENDED USE [1 Domestic/Private(Irrigation/Agricultural 7. Industrial [: Water Quality Monitoring r; Soil Sampling/Characterization <br />Public Water Syst m <br />If different from Owner. Water System Name Contact Name or Phone Number <br />TYPE OF WORK - New Well Replacement Well C Well Alteration/Modification i'. Other <br />Monitoring Well(s) of wells D Soil Boring(s) kof bodnCs Geotechnical 9.fborings <br />Out-0fService Well D Out -Of -Service Well Renewal Cross -Connection Repair <br />Drilling Method Mud Rotary Air Rotary -_ Auger Cable Tool Push Point C Other <br />Proposed Well Depth ft Excavation in diameter :1 Open Bottom r, Gravel Pack/Gravel Size In diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched " Steel ❑ Plastic n Stainless Steel f1 Other <br />Grout Seal Depth It Neat Cement (941b bag/5-10 gal water) ['. Sand Cement sack mix17 gal water <br />Bentonite (20% solids) _ Other <br />Grout Placement Method -' Pumped : Free Fall L Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller _ Pump Contractor C Other <br />Concrete Pedestal '_Dimensions: Width It Length It Thick in i i Christy Box ❑ Stove Pipe <br />PUMP "- Submersible:"i Turbine '] Other HP= Pump Set 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 COMPENSATION LAWS. <br />r;*.P}f!� 1tc'�TIr^��, >•ntrt,�t-;. Jnr, r1[':'i�Dt(,.`��T�� ^�/x}C `.�,r.x' _ is "•,t.. f. t. ,.... °t ))`�f �I y� .. �. <br />SIGNED -'�C.c .... .. J _ - . TITLE ( .DATE (� •d0 ��'( <br />✓-DEPARTMENT USE ONLY <br />Application Accepted By .0 Date lr�e✓� i Area Employee ID# <br />Grout Inspection By Date A SPECIAL Well Permit <br />Pump Inspection By lh '' Date Z Z L D WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />PE SC Received Check#! Amount ate PermiU Invoice # Well ID# <br />Codes Info Cash Remitted Service Re uest# <br />Y J•7 71 <br />FH04306 6111/2019 � -r ' iT7 � /7 V / 421 J( <br />r.! i' II��.... 1/ (i WELL (PUMP PERMIT <br />