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t <br />WELUPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 -6232 (209) 46813420 <br />WREFUNDABLE PERMIT www.Sjgov.org/ehd EXPIRES i YEAR FROM DATE ISSUED <br />ADDRESS 9942 E Copgeropol;G Ra Crrr21PSt-0Ckt.nM,CA 0.5215 <br />SS STREET Bern Rd APN 10309001 PARCEL SO4_0.�LAND USE AP,PUCATION # <br />IERNAME Sherrie Genet -t-; PHONE <br />IERADDRESS 9942 R C'nP,narnnnl LS Rd CITY/STATE21PSf-nrktnnXA 91,21S <br />TRACTOR Purviance Drillers, INC PIONE209-887-3554 <br />TRACTORADDRESSP-0. BOX 64 CmISTATEMPLinden CA 95236 <br />TAM <br />PHONE <br />SUBCONTRACTOR/CONSULTANT ADDRESS CrrY/STATE/ZIP <br />LICENSE R C-57 D C-61 71 D-09 Other NUMBER 377923 EXPIRAnoN DATE 7/31/23 <br />BILLING PARTY: :j OWNER " CONTRACTOR SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: (i General Mineral/Coliform Bacteria (4391) .-1 Dibromochloropropane (4392) ❑ Arsenic (4393) <br />'.NTENDED USEomestic/Private 17 Irrigation/Agricultural Industrial Water Quality Monitoring ; Soil Sampling/Characterization <br />Public Water System <br />H *ffersnt from Owner: Water System Name Contact Name or Phone Number <br />I Tre ul-yyoRK .; New weii L Keplacement Well C Well Alteration/Modification Ci Other <br />I Monitoring Well(s) #of wells SoilBoring(s) a°thonrgs L Geotechnical Fotbo in.. <br />7 Out -Of -Service Well Out -Of -Service Well Renewal D Cross -Connection Repair <br />J New Pump 'X PUmo Reolacement PumD Reoair Raises Well rashes, <br />Drilling Method " Mud Rotary : Air Rotary __ Auger C; Cable Tool ❑ Push Point E Other <br />Proposed Well Depth It Excavation in diameter 11 Open Bottom a Gravel Pack/Gravel Size in diameter <br />C Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ In Thickness/Gauge/ASTM Sched ! 1 Steel -_Plastic i i Stainless Steel I Other <br />Grout Seal Depth ft -_Neat Cement (941b bag/S-10 g.;water) Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) D Other <br />Grout Placement Method _. Pumped :, Free Fall ❑ Other Retardant / Accelerator (name) <br />PEDESTAL Installed By � Driller Pump Contractor L Other <br />C Concrete Pedestal Dimensions: Width It Length ft Thick in Christy Box L Stove Pipe <br />PUMP ubmersible _: Turbine - Other HP Pump Set It Standing Water Level ft <br />1 HEREBY CER IFY 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 />` j� ... t . ...... 7..t_L3f%.. J�'p3C.t S. . _./l�uE GALS (2®9) 9s3... <br />GNED �j CU.�! :J.i!'//•_aL�C t� TRLE (�'¢�� 0�1'£!'t-u� DATE �4 /•2 S /2 - <br />SI i <br />DEPARTMENT USE ONLY <br />Application Accepted By _7 Date :36 ✓ I Area r/ Employee ID# J <br />Grout Inspection By }pale / i I SPECIAL Well Permit <br />Pump Inspection By ( H_'ODate ( ❑ WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />PESC <br />Codes Info <br />93IS? Po$' <br />Amount Date <br />Invoice # <br />Well ID# <br />EHD d}p8 6111=19 <br />WELL /PUMP PERMIT <br />a <br />QUIN <br />ONMENOUNTy <br />)Fpq R TMFN r <br />