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I - ~ r <br />WELUPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1668 EAST HAZELTON AVENUE-STOCKTON CA 95205 -6232 (209) 468-3420 <br />NUN-KEFUNDABLE PERMIT www.sl9ov.org/ena tAt'IKtJ 7 TEAR FROM UATE ISSUED <br />JOBADDRESS 13115 E Baker Rd Cm•216tockton.Ca 95215 <br />CROSS STREET ja C k t o n P Rd APN 0891C)()3" PARCEL SIZE 20_LAND USE APPLICATION # <br />OWNERNAME Rick Manai I i PHONE (t")) 6-10 <br />OWNER ADDRESS 1' 115 F R3]Ccr Rrl CITY/STATE/ZIP St.00kton,CA 95215 <br />CONTRACTOR Purviance Drillers, INC PHDNE209-887-3554 <br />CONTRACTOR ADDRESS P.O. BOX 64 CITY/STATE/ZIPL i nd e n CA 95236 <br />SUBCONTRACTORICONSULTANT <br />LICENSE �. C-57 <br />BILLING PARTY_ <br />.TANT ADDRESS <br />C-61 D-09 _ Other <br />OWNER ..: CONTRACTOR <br />CITYISTATE/ZIP_ <br />NUMBER 377923 <br />SUBCONTRACTOR/CONSULTANT <br />PHONE <br />EXPIRATION DATE 7/31 /23 <br />DOMESTIC WELL SAMPLING: F General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) 1' Arsenic (4393) <br />NTENDED USE Domestic/Private - Irrigation/Agricultural Industrial _ Water Quality Monitoring I . Soil Sampling/Characterization <br />Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK D New Well f': Replacement Well 2 Well AlterationlModification .. Other <br />Monitoring Well(s)—# of wells ❑Soil BoringR of bodngs s) 1 Geotechnical a<of borings <br />D vice Out-Of-SerWell Ci Out -Of -Service Well Renewal Cross -Connection Repair <br />n..__ '/ --o__ ______. _ r,..__ <br />Drilling Method _ Mud Rotary Air Rotary Auger Cable Tool Push Point Other . <br />Proposed Well Depth ft Excavation in diameter �] Open Bottom C Gravel Pack/Gravel Size inp r <br />- Conductor Casing in diameter I Conductor Casing Depth ft F NEQ <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched Steel -. Plastic - Stainless Steel a Other L <br />Grout Seal Depth ft G Neat Cement (941b bag/5-10 gat water) i Sand Cement sack mix/7 gal water <br />L Bentonite (20% solids) Other <br />Grout Placement Method Pumped _ Free Fall L Other - Retardant / Accelerator (name) <br />PEDESTAL Installed By T Driller - Pump Contractor - Other <br />Concrete Pedestal Dimensions: Width ft Length ft Thick in C Christy Box D Stove Pipe <br />PUMP Submersible Turbine Other HP Pump Set �O R Standing Water Level �_ ft <br />I HEREBY CERTIFY THAT 1 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 COMPETATIO i LAWS! 1 <br />S <br />IPgYM� <br />RF�FI�NT <br />4UG24 � <br />?021 <br />��QU/ <br />"AlIENT <br />DEPARTMENT USE ONLY <br />J C GMs <br />Application Accepted By � Date �� Area r t Employee ID# <br />Grout Inspection By I, Qate 1 SPECIAL Well Permit <br />Pump Inspection By �� .�c�Jj ate -1 WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />PE <br />Codes <br />94 3` f <br />Sc Received Check#/ Amount PePermit)# <br />e S R e t # Invoice Well ID# <br />Info Cash Remitted ?1. <br />D:p 4,77tqcj <br />EHD 49A6 fi111/2019� / // --h' WELL !PUMP PERMIT <br />