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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1668 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 4683420 <br />ry VIV-RtF UNUAtdIE PERMIT <br />EXPIRES 1 YEAR FROM DATE ISSUED <br />JOBADDRESS 11600 E Harmony Grove Ln CITY21P <br />CROSS STREET Thretheway Rd APN O 51 1 8 0 4 2 PARCEL SIZE 4 6 2 LAND USE APPLICATION # <br />OWNERNAME Dave Pa)4np PHONE <br />OWNERADDRESS 10,00 R Hgrmnnv C,rnvp Tn CITYISTATE21PLocke ford, CA 95237 <br />CONTRACTOR Purviance Drillers, INC PHONE209-887-3554 <br />CONTRACTOR ADDRESS P- 0- BOX 64 CITYISTATVZIPL i nden CA 95236 <br />.TANT ADDRESS <br />LICENSE k C-57 _ C-61 D-09 i' Other <br />BILLING PARTY: OWNER :j CONTRACTOR <br />CITYISTATE/ZIP_ <br />NUMBER 377923 <br />is SUBCONTRACTORICONSULTANT <br />PHONE <br />EXPIRATION DATE 7/ 3 1/ 2 1 <br />DOMESTIC WELL SAMPLING: i . General Mineral/Coliform Bacteria (4391) �l Dibromochloropropane (4392) 11 Arsenic (4393) <br />NTENDED USE 'X-Domestic/Private ❑ Irrigabon/Agricultural [; Industrial _; Water Quality Monitoring 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 1: Replacement Well ❑ Well AtterafionlModification ❑ Other <br />Monitoring Well(s) # of wells D Soil Boring(s) x of bodngs Geotechnical a of borings <br />Out -Of -Service � 15/Pump <br />11 Out -Of -Service Well Renewal i' Cross -Connection Repair <br />New Pump ay/Pump Replacement n Pump Repair Raise Well Casino <br />Drilling Method Mud Rotary Air Rotary : Auger F Cable Tool Push Point I Other <br />Proposed Well Depth ft Excavation _ in diameter tl Open Bottom [I Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched 7 Steel ❑ Plastic i I Stainless Steel I i Other <br />Grout Seal Depth ft Neat Cement (94 lb bag/5-10 gal water) I I Sand Cement sack mix/7 gal water <br />C Bentonite (20% solids) t1 Other <br />Grout Placement Method _ Pumped _ Free Fall L Other Retardant / Accelerator (name) <br />PEDESTAL Installed By L Driller _ Pump Contractor L Other <br />C Concrete Pedestal '_;Dimensions: Width ft Length ft Thick in ['. Christy Box C Stove Pipe <br />PUMP - Submersible'; Turbine _Other HP 21 Pump Seti l0 ft Standing Water Level v�u 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 1 AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />SIGN�46' . zyt�GG TITLE �r'ilir-�/it''7T DATE , /'��._�'/ <br />DEPARTMENT USE ONLY <br />Application Accepted By �+/`' Date -' d Area I i Employee ID# <br />Grout Inspection By Date 7 SPECIAL Well Permit <br />Pump Inspection By �iit., r . S t l�•,vti r Z Date (Z (�j'l1 w �' 1 WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />N <br />PE <br />Codes <br />Sc Received Check#/ Amount Date Permit/ Invoice # Well ID# <br />Info Cash Remitted ervice Re uest# <br />EHD 43-06 61772019 /` <br />7if/L /2—F 76-777 WELL /PUMP PERMIT <br />