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• WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 466-3420 <br />IVVIY-RtFUNUAtiLE YEHMIT WWW.S ov.ot' /encl IcXPIRES 1 YEAR FROM DATE ISSUED <br />JOBADDRESS 14650 St Rt Hwy 26 Crr(mPLinden.CA 95236 <br />CROSS STREET Fanning Rd APN 10507006 PARCEL SIZE 5 . 0 LAND USE APPLICATION # <br />OWNER NAME <br />PHONE <br />OWNER ADDRESS 14404 F St Rt Hw)z 26 CITYISTATEmP T.]. n Ljen ('A 957-1Fi <br />CONTRACTOR Purviance Drillers, INC PHONE2 0 9 - 8 8 7 - 3 5 5 4 <br />CONTRACTOR ADDRESS P - 0- BOX 64 Cm/STATE/ZiPLinden CA 95236 <br />SUBCONTRACTOR/CONSULTANT <br />ADDRESS <br />X C-57 C-61 J D-09 Other <br />PARTY: ;:OWNER -CONTRACTOR <br />CITYISTATEmP_ <br />NUMBER 377923 <br />1 SUBCONTRACTOWCONSULTANT <br />PHONE <br />EXPIRATION DATE 7/31/23 <br />DOMESTIC WELL SAMPLING: G General Mineral/Coliform Bacteria (4391) Ci Dibromochloropropane (4392) C Arsenic (4393) <br />INTENDED USE Domestic/Private -, Irrigation/Agricultural Industrial :7 Water Quality Monitoring � 1 Soil Sampling/Characterization <br />Public Water System <br />If different from Owner. Water System Name Contact Name a Phone Number <br />TYPE OF WORK C New Well C Replacement Well Well Alteration/Modification ; : Other / <br />C Monitoring Well(s) # of wells Soil Boring(s) a of borings Geotechnical of bonngs l <br />D Out -Of -Service Well C Out -Of -Service Well Renewal ❑ Cross -Connection Repair `SA IV '10 <br />0 New Pump Xpump Replacement , Pump Repair r Raise Well CasingE <br />WELL CONSTRUCTION <br />Drilling Method Mud Rotary Air Rotary Auger Cl Cable Tool Push Point C Other <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom J Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Schad Steel ❑ Plastic Stainless Steel t Other <br />Grout Seal Depth ft , Neal Cement (941b bagl5-10 gal Water) 0 Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) D Other <br />Grout Placement Method 7. Pumped 5 Free Fall C Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller L Pump Contractor L Other <br />C Concrete Pedestal !_Dimensions: Width ft Lengthft Thick in Christy Box ❑Stove Pipe <br />PUMP Submersible(: Turbine 7 Other HP Pump Set' ft Standing Water Level <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 WIT E CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION <br />t1A,14C1? n)r1 { F{ c Fri t1I3!1 c ?' F(1P11A�rt]n7ln!!n$�' i°1fi S�? <br />F f !1.!. +;:C9` F:n_. P,. <br />.. <br />SIGNED TITLE \ -O "a'y 0, Jib �� DATE fi <br />DEPARTMENT LASE ONLY <br />Application Accepted By �L L Date 91 -W:' -A? Area Employee ID# � <br />Grout Inspection By ate 1 SPECIAL W611 Permit <br />Pump Inspection ByVLA /jn� Date WAIVER Received <br />Soil Boring Inspection_ By Date 1 Constructed Well Depth -ft <br />COMMENTS -1 U Or i hC to L c. t I C) '1 <br />r <br />N <br />EENT <br />l VF6 <br />'25 2021 <br />?0//V C <br />N�V7A <br />ANTY <br />MEN., <br />PE SC Received <br />Codes Info By- <br />Check#! Amount D Permit/ Invoice # Well ID# <br />Cash Remitted Servi e u <br />3 I U y <br />SOL 1' ! <br />l <br />EHD43-06 6111x:019 �/7. `J� / — / WELLIPUMPPERMIT <br />