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WELL / PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER -rE 3"a FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED JOB ADDRESS 8742 N. Clments Rd. CITY/ZIP Linden CA 95236 I CROSS STREETComstock APN r (7p--I,? PARCEL SIZE 5'(,.'t-7 9 OWNERNAME Alberta Lewallen PHONE OWNERADDRE55 8742 N. Clements Rd. CITY/STATE/ZIP Linden CA 95236 CONTRACTOR Purviance Dr:llers, Inc. PHONE 209-887-3554 f CONTRACTOR ADDRESS P-0.Sox 6 4 E CITY/STATE)ZIP Linden CA 95236 SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE 9 C-57 ❑C-61 O D-091 ❑Other NUMBER 377923 EXPIRATION DATE_?/31 /0 5 GEOGRAPHICAL INFORMATION: Coordinates I X Y Township Range Section INTENDED USE N Domestic/Private ❑Irrigation/Agricultural is Industrial ❑Water Quality Monitoring 0 Soil Sampling/Characterization ❑Public Water System I If different from Owner: Water bystem Name Contact Name or Phone Rumber TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other ❑Monitoring Well(s) number of ©Soil Boring(s) ❑Geotechnical wells number of borings number orborings ❑Well Destruction ❑Out-Of-Service Well 0 Out-Of-Service Well Renewal ❑New Pume ❑Pump Replacement ❑Pump Repair ❑Cross-Connection Repair WELL CONSTRUCTION I Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool 0 Push Point 0 Other Proposed Well Depth ft Excavation in diameter 0 Open Bottom ❑Gravel Pack 1 Gravel Size in diameter ❑Conductor Casing I in diameter / Conductor Casing Depth L ft Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other Grout Seal Depth ft ❑Neat Cement(44 Ih hag 15-10 gal water) ❑Sand Cement suck mix/7 gal water 0 Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File 0 Specs Submitted Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By ❑Drillcr 0 Pump Contractor ❑Other 0 Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑Christy Box 0 Stove Pipe Pump N Submersible ❑Turbine 0 Other HP 5 Pump Set 21 0 ft Standing Water Level ft WELL DESTRUCTION ❑Open Bottom 1 ❑Gravel Pack 0 Uneased ❑Other Well Diameter in Total Depth ft Depth to Water ft ❑Casing to be Perforated from ft to ft Sealing Material 0 Neat Cement(94lhbag/5-10ga1 water) 0 Sand Cement sack mix/7 gal water ❑Bentonite Pellets } ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name 0 Specs on File ❑Specs Submitted E Placement Method ❑Pumped ❑Free Fall 0 Other ❑Complete with Mushroom Cap ft below grade ❑Complete to Existing Surface Pad 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORT{ WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. I M U OU DVANCE NOTICE REQUIRED FOR INSPECTIONS--PLEASE CALL(209)953-7697 SIG TITLE Corporate Secretary DATE 7/2/04 � I I � I ( 1 N IR N EN AL -HEALI H-1 EP RT E - - DEPARTMENT USE NL Application Accepted By �� Date F L Area �-/Z Employee I D# -}3�'�' ��q j Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By n—(1"kn , Date__LLq-QW ❑ WAIVER Received Destruction Inspection By Date Constructed Well Depth ft COMMENTS PE SC Received Check# Amount Permit/ Codes Info By s Remitted Date Service Request# Invoice# Well ID# 43•C-1 O.so 97: St 7 t7 Q 0 I EHD 43-02-006 MASTER WATER WELL PERMIT 12/6/2002