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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />NUN -REFUNDABLE PERMIT WWw.S <br />P1 <br />ov.of /ehd <br />"—u <br />EXPIRES 1 YEAR FROM DATE ISSUED <br />JOBADDRESs 22696 Buena V; a Rcj <br />CITYIZIP�em <br />�ts,('A 95777 <br />CROSS STREET S t Rt Hwy 88 APN 0 21 21 0 31 <br />PARCEL SIZE 20 o LAND USE APPLICATION # <br />OWNERNAME Wolf & Wolf Rar1C)'1IncPHONE <br />OWNERADDRESS 1448 Mpa Ansi <br />Ava <br />CITYISTATE1ZP-.Stnr•kt-_,'CA <br />q5907 <br />I�CONTRACTOR Purviance Drillers, INC <br />PHQNE209-887-3554 <br />CONTRACTOR ADDRESS P•0• BOX 64 <br />cm/STATEZpLinden CA 95236 <br />SUBCONTRACTOR/CONSULTANT <br />PHONE <br />SUBCONTRACTORICONSULTANT ADDRESS <br />CITYISTATE/LP <br />LICENSE RC -5T ..: C-61 i! D-09 i! Other <br />NUMBER 377923 <br />EXPIRATION DATE 731 21 <br />BILLING PARTY: ::OWNER �'. CONTRACTORS: <br />SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: r; General Mineral/Coliform BantAria (43Q1) nih..,..,.,,.tiL..------------ <br />....... ---- <br />P1 OF-- i,4oac/ a ArSenIC (4393) <br />WENDED USE ;<"Domestic(Private IrrigatioNAgricultural - Industrial Water Quality Monitoring i 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 New Well r <br />timer <br />Monitoring Well(s) # of wells L Soil Boring(s) # of borings I Geotechnical # of borings <br />Out -Of -Service Well U Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />New Pump 'YPumpReplacement 11PumoReoair r,o.,:-..,,,,_,,.__.__ <br />Drilling Method Mud Rotary C Air Rotary Auger L Cable Tool C Push Point - Other <br />Proposed Well Depth ft Excavation in diameter i 1 Open Bottom n Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter <br />—in Thickness/Gauge/ASTM Sched C Steel L' Plastic F1Stainless Steel ; I Other <br />Grout Seal Depth ft Neat Cement (941b ba9/5-10 gal water) ❑ Sand Cement <br />Bentonite (20% solids) D Other sack mixl7 gal water <br />Grout Placement Method Pumped -_ Free Fall 11 Other i.; Retardant / Accelerator (name) <br />PEDESTAL Installed By - Driller � Pump Contractor L Other <br />C Concrete Pedestal _.Dimenslons: Width ft Length.. ft Thick in Christy Box _I Stove Pipe <br />PUMP Submersible' Turbind - Other <br />HP Pump Set NC._f--2 Standing Water Level _\ G"/ ft <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE SAINS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />en <br />N <br />U=rAKIMENT USE ONLY <br />Application Accepted By �7, . �� Date i Area l <br />f Employee IDI/ EP <br />Grout Inspection By Date 1 SPECIAL Well Permit <br />Pump Inspection By _ ,;y; -, J- ,. , ti Date �� �� �?, ]� WAIVER Received <br />Soil COMMENTS Boring Inspection By Date Constructed Well Depth ft <br />_+f�.r c t ^ y t. r z✓ �4,i �1Zylzs; <br />O <br />Invoice # <br />Well ID# <br />EHD 43-06 6/11/2019 ( / / 2 ` 2-9 / .1— Zo <br />WELL lP(,IM'r PERMIT <br />y <br />