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r <br />WELL/PUMP PERMIT <br />SAS: JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />NON-REFUNDABLE PERMIT www.s ov.or/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />JOBADDRESS 1 7205 Copperopolis Rd CITY/ZIP Linden, CA 95236 <br />CROSS STREET D ii n C' a n R d APN 1 0 51 1 0 2 5 PARCEL SizE42. 3 4 LAND USE APPLICATION # <br />OWNERNAME V & A Lagorio j l Y�-� <br />PHONE � � / �" <br />OWNER ADDRESS C m ock RD CrrYISTATE/zP Linden, CA 95236 <br />CONTRACTOR Purviance Drillers INC <br />PHONE209-887-3554 <br />CONTRACTOR ADDRESS P- 0. BOX 64 CITY/STATE/ZIPL i nd en CA 9 5 2 3 6 <br />SUBCONTRACTORICONSULTANT <br />PHONE <br />SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP <br />LICENSE X C-57 C-61 D-09 other NUMBER 377923 7/31/23 <br />EXPIRATION DATE <br />BILLING PARTY: :_; OWNER :; CONTRACTOR IJ SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: C; General Mineral/Coliform Bacteria (439 1) ❑ Dibromochloropropane (4392) 11 Arsenic (4393) <br />INTENDED USE omestic/Private ❑ Irrigation/Agricultural 0 Industrial ❑ Water Quality Monitoring L Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Owner. Water System Name Contact Name or Phone Number <br />TYPE OF WORK L New Well L Replacement Well 0 Well Alteration/Modification ❑ Other <br />Monitoring Wells) # of wells ❑ Soil Borinb(s) # of borings ❑ Geotechnical # of borings <br />U Out -Of -Service Well 0 Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />New Pump *ump Replacement 0 PRepair w r Pump p ❑Raise Well Casino <br />Drilling Method Mud Rotary :1 Air Rotary n Auger a Cable Tool i_' Push Paint :1 Other <br />Proposed Well Depth ft Excavation in diameter ']Open Bottom F1Gravel Pack/Gravel Size <br />_1 Conductor Casing in diameter / Conductor Casing Depth ft in diameter <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched I ; Steel ❑ Plastic 1i Stainless Steel n Other_ <br />Grout Seal Depth ft Neat Cement (941b ba 10 gal water) [] Sand Cement <br />U Bentonite (20% solids) 0 Other sack mix/7 gal water <br />Grout Placement Method :I Pumped ❑ Free Fall [i Other G Retardant /Accelerator (name) <br />PEDESTAL Installed By Driller U Pump Contractor U Other <br />Concrete Pedestal EDimensions: Width ft Length ft Thick <br />in U Christy Box C Stove Pipe <br />rumv Submersible[-, Turbine �i Other HP Pump Set 19 ft Standing W s Level l <br />•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, S ATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE <br />WORKERS COMPENSATION LAWS. BOARD AND THAT t AM IN COMPLIANCE WITH ALL <br />Q� yt�q t <br />I^ f> .11VAC�Sr E NC}TT :T e', t- <br />PLEASE CALL (20C' .. , . <br />SIGNED <br />TITLE O Atli DATE J 7 <br />DEPARTMENT USE ONLY <br />Application Accepted By � i%,�_ Date I r � /, j ) t <br />Grout Inspection By Date <br />Pump Inspection By <br />Date <br />Soil Boring Inspection By Date <br />COMMENTS <br />Date <br />Area )I G 6 Employee ID# <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth <br />Invoice # <br />Well ID# <br />ft <br />EHD43-06 6/11/2019 <br />S� I / `U Tv 2_' WELL /PUMP PERMIT <br />T <br />m <br />m <br />D <br />0 <br />0 <br />A <br />y <br />N <br />IENT <br />IVSD <br />7 2021 <br />COUNT`( <br />