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r <br />SAN.IOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENTELUPUMP PERMIT <br />1868 EAST HAZELTON AVENUE - STOCKTON CA 95205.6232 (209) 4683420 <br />NON-REFUNDABLE PERMIT www.sogov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />JOBADDRESS P Shelton Rd CITylziCinden CA 95236 <br />CROSS STREET__ W—�r ] V R d APO3 3 10 0S <br />PARCEL SIZE1_Ej_LAND USE APPLICATION # <br />OWNERNAME Aa West - Olivet" Ranch <br />PHONE <br />OWNERADDRESS —Po. BOX 739 CITY/STATEMP Linden, CA 95236 <br />CONTRACTOR Purviance Drillers INC <br />PHONE209-887-3554 <br />CONTRACTOR ADDRESS P- 0- BOX 64 CrrY/STATEIZIPL i nden CA 95236 <br />SUBCONTRACTOWCONSULTANT <br />PHONE <br />LCONTRACTORICONSULTANT ADDRESSCITYiSTATE/ZIP <br />NSE C-57 ❑ C-61 C D-09 U Other NUMBER 377923 EXPIRATIONDATE 7/31/21 <br />ING PARTY: i OWNER _'. CONTRACTOR J SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: G General MineraUColiform Bacteria (4391) �: Dibromochloropropane (4392) ❑ Arsenic (4393) <br />G Pub IicWaterSys <br />tb <br />If different from Owner: <br />n Industrial Water Quality Monitoring ;,Sod Sampling/Characterization <br />;Y—Stem Nam. ConlaU Name or Phone Number <br />wVKR <br />L. New wen C Replacement Well Well Alteration/Modification :! Other <br />MonitoringWell(s) Of wells SoilBoring(s) a0fborings ;i Geotechnical or bo ngs <br />2 Out -Of -Service Well 'I Out -Of -Service Well Renewal C Cross -Connection Repair <br />New P,— y D,,,..., D....i,.....�__. .- <br />Drilling Method = Mud Rotary .-' Air Rotary 17 Auger Cable Tool Push Point I1 Other <br />Proposed Well Depthft Excavation in diameter :I Open Bottom ❑ Gravel Pack/Gravel Size <br />in diameter <br />Conductor Casing in diameter / Conductor Casing Depth g <br />Well Casing Diameter _ in ThicknesslGauge/ASTM Schad 7 Steel Ei Plastic f I Stainless Steel a Other <br />Grout Seal Depth ft -1 Neat Cement (941b bagl5-10 gal water) ; Sand Cement <br />Bentonite (20% solids) Other sack mix/7 gal water <br />Grout Placement Method Pumped .. Free Fall C Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller Pump Cont actor Other <br />Concrete Pedestal :: Dimensions: Width ft Length ft Thick <br />in ❑Christy Box i s Stove Pipe <br />PUMP `.: Submersihle Turbine ^ Other HD7 n( n i <br />I+ It branding Water Level JAL It <br />I HEREBY CERTIFY THAT 1 AVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. 1 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 COMPENSATION LAWS. <br />p11 <br />q r <br />C. or <br />23 20?, <br />JiN C <br />1111 <br />61vouNTY <br />MFNT <br />UCI'AK I MENT USE ONLY L' <br />Application Accepted By `r_ Date F / Area �i �i fr, 5 <br />Employee ID# <br />Grout Inspection By to rl SPECIAL Well Permit <br />Pump Inspection By !TrDate - -1 WAIVER Received <br />Soil Boring Inspection By Date <br />COMMENTS Constructed Well Depth ft <br />