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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 />N-KEFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />ADDRESS j SF72 E rnmGtnCk R-9 CITYMPLinden,CA 95236 <br />SS STREET Tul l V Rd APN O 91 0 9 O 0 2 PARCEL SIZ9 9 . 6 9 LAND USE APPLICATION # <br />IER NAME G i rnlC r'i'll 63;1,>1/✓`1 C PHONE <br />IERADDRESS 11-502 E, Ei qht Mile Rr1 CrTY/STATE/ZIPStQQkton, CA 95212 <br />TRACTOR Purviance Drillers, INC p.ONE209-887-3554 <br />TRACTOR ADDRESS P.O. BOX 64 CITY/STATE21PLlnden CA 95236 <br />TANT <br />TANT ADDRESS <br />X C-57 _ C-61 D-09 <br />PARTY: OWNER <br />PHONE <br />CITY/STATE/ZJP <br />Other NUMBER 377923 EXPIRATION <br />CONTRACTOR = SUBCONTRACTORICONSULTANT <br />7/31/23 <br />DOMESTIC WELL SAMPLING: f- General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) i : Arsenic (4393) <br />INTENDED USE 1 Domestic/Private Irrigation/Agricultural !7 Industrial :: Water Quality Monitoring 0 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 I' Replacement Well ;: Well Alteration/Modification Other <br />D Monitoring Well(s) # of wells = Soil Boring(s) : of borings Geotechnical 'A of bonngs <br />0 Out -Of -Service Well L Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />:7 New Pump -' Pump Replacement `Pump Repair 1;,r-..y�i�_ Raise Well Casino ^ DA a <br />Drilling Method Mud Rotary , Air Rotary 1 Auger _ Cable Tool I; Push Point ' I Other Sq <br />Proposed Well Depth ft Excavation in diameter U Open Bottom Gravel Pack/Gravel Size ENIV41g <br />Conductor Casing in diameter / Conductor Casing Depth ft LTH pEF <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Schad r: Steel Plastic I1 Stainless Steel [I Other <br />Grout Seal Depth ft _: Neat Cement (94 lb bag/5-10 gal water) Sand Cement sack mix/7 gal water <br />_ Bentonite (20% solids) 0 Other <br />Grout Placement Method Pumped 'j Free Fall ❑ Other Retardant / Accelerator (name) _ <br />PEDESTALInstalled By Driller D Pump Contractor L Other <br />Concrete Pedestal i.Dimensions: Width ft Length ft Thick in i] Christy Box7 Stove Pipe <br />PUMP Submersible, Turbine El OtherHP = Q Pump Set k` , 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,-'l�"kt'�F: '1nv:rc p-n..,__.� T..... 'PI ��..—, -^{+�..,,-• -,i -n. ':- ^n� - <br />N <br />m <br />D <br />0 <br />A <br />N <br />IVIED <br />20?? <br />cNTA NTy <br />RTIOENT <br />DEPARTMENT USE ONLY <br />Application Accepted By e �<—�i� Date L 5 c�c� Area / �% Employee ID# <br />Grout Inspection By Date 1 SPECIAL Well Permit <br />Pump Inspection By oa. Date -I WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />4AZ4 L) _l Z. l <br />PE SC Received <br />Codes Info <br />Check#/ <br />Cash <br />r — <br />AmountPermit/ <br />Remitted ate Service Re uest # Invoice # Well ID# <br />'NIECE !PUMP PERMIT <br />