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WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468-420 <br /> NON-REFUNDABLE PERMIT www.sigov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 27050 E. Flood Rd CITYIZIP Linden,CA 95236 <br /> M <br /> CROSSSTREET Escalon Bellota RDApN PARCEL SIZE 07 LAND USE APPLICATION# <br /> 0 <br /> OWNERNAME G.B. Ranches PHONE2D9 3887-1878 <br /> OWNERADDRESS P-0- BOX 673 CIT,/STATEMI.Linden,CA 95236 <br /> CONTRACTOR Purviance Drillers, INC PHONE209-887-3554 <br /> CONTRACTOR ADDRESS P-0- BOX 64 CITY/STATE/ZIPL i nden CA 95236 <br /> SUBCONTRACTORICONSULTANT PHONE <br /> SUBCONTRACTORICONSULTANT ADDRESS CRY/STATEZP <br /> LICENSE X C-57 C-61 i:D-09 ::Other NUMBER 377923 EXPIRATION DATE 7/31/21 <br /> BILLING PARTY: --OWNER _:CONTRACTOR :: SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING:C General Mineral/Coliform Bacteria(4391)n Dibromochloropropane(4392)C Arsenic(4393) <br /> INTENDED USE Domesbc/Private lingation/Agricultural is Industrial [i Water Quality Monitoring C Soil Sampling/Characterization }/M- <br /> C Public Water System <br /> Omer. �" • / <br /> If different from Omer. System Name Contact Name or Phone Number <br /> TYPE OF WORK :i New Well C Replacement Well Well Alteration/Modification C Other �D <br /> 'I Monitoring Well(s) #of wells '7 Soil Borin s �ofborings Geotechnical #cfbonn s <br /> P ,� <br /> Out-Of-Service well Out-Of-Service Well Renewal C Cross-Connection Repair sq ?O?O <br /> New Pump Pump Replacement ::Pump Repair C Raise Well CasingN <br /> WELL CONSTRUCTION �A/ <br /> Drilling Method .Mud Rotary Air Rotary ; /1 Auger "Cable Tool i s Push Point Other H�QCT�o Q/vIc u <br /> R <br /> Y <br /> Proposed Well Depth Excavation in diameter C Open Bottom F!Gravel Pack/Gravel Size in diameter M <br /> Conductor Casing in diameter / Conductor Casing Depth ft �N r <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched t,Steel is Plastic ;l Stainless Steel I Other <br /> Grout Seal Depth ft =Neat Cement(941b bag/5-10 gal water) Sand Cement sack mixr7 gal Water <br /> Bentonite(20%solids) ❑Other <br /> Grout Placement Method 7 Pumped ;Free Fall C Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor E Other <br /> Concrete Pedestal^,Dimensions:Width ft Length ft Thick in Christy Box _Stove Pipe <br /> PUMP :l Submersible_ .,bine L Other HP Pump Set _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 COMPENSAT LAWS. <br /> { % /� kD,nVA'NCE NOTICE P%EC?t)IRED 7 *Ig.,to+encr.CALL!^7a)er3--na <br /> SIGNED' 'fLu-' <br /> TITLE fir=' .- DATE <br /> —————————————————————————MI '-, -- <br /> n <br /> DEPARTMENT USE <br /> ONLY <br /> Application Accepted ByDate % �7 s�Jr Area y/ /' / <br /> Employee ID# <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By 1-z fL.! Date z!"43_1:. D WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check* Amount Permit/ <br /> Codes Info sh Remitted Date Service Re .est# Invoice# Well ID# <br /> 1U . <br /> 'I <br /> EHD 63-06 8/11,1019 <br /> WELL]PUMP PERMIT <br />