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r <br /> WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 6232(209)468-3420 <br /> NON-REFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDR S & E Harney Ln CmILv Lodi m <br /> 067-040-090 <br /> CROSS STREET �'—'` APN PARCEL SIZE '� LAND USE APPLICATION A n <br /> OWNER NAME Berghill, LLC PHONE 209-888-5465 <br /> OWNER ADDRESS PO Box 739 CRYISTATEIZIP Linden, CA 95236 <br /> CONTRACTOR Purviance Drillers, Inc PHONE209-887-3554 <br /> CONTRACTOR ADDRESS PO Box 64 Ctrs/STATEfZIPL i rid en, CA 95236 <br /> SUBCONTRACTORICONSULTANT n a PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS n/a CITY/STATEIZIP <br /> LICENSE 9(C-57 C-61 I D-09 L'Other NUMBER <br /> 3 7 7 9 2 3 EXPIRATION DATE 7/31 /21 <br /> BILLING PARTY: OWNER -CONTRACTOR SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392).-Arsenic(4393) <br /> [LNTENDED USE Domestic/Pnvate jpmgation/Agricultural Industrial -Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If diffamnt from Owner Water System Name Conlad Name or Phone Number <br /> TYPE OF WORK )(New Well .Replacement Well --Well Atteration/Modification .=Other PgYME <br /> Monitoring Wells) S of wells Soil Bonng(s) N of bongs Geotechnical 0 of bodags NT <br /> Out-Of-Service Well Out-Of-Service Well Renewal ...Cross-Connection Repair CE,1/�DI <br /> New Pum Pum Replacement - Pum Repair _Raise Well Casingr <br /> WELL CONSTRUCTION P O <br /> Drilling Method xMud Rotary Air Rotary Auger Cable Tool -.Push Point Other ?020 <br /> Proposed Well Depth/LMV_R Excavation,.2.2_in diameter sX Open Bottom Gravel PacklGravel Size in dl E AQV/N <br /> Conductor Casing_NZA in diameter / Conductor Casing Depth R /V O C00V11' <br /> Well Casing Diameter jf& in Thidmess/Gauge/ASTM Sched •�d )(Steel Plastic Stainless Steel Other y�� Q /VWW', C <br /> Grout seal Oept�i±-- .fl Neat Cement(94 lb bag/5-10 gal water) y Sand Cement �0.3 sack mix?gal water EpAR7-&f /VT <br /> Bentonite(20%solids) - Other <br /> Grout Placement Method Pumped Free Fall Other ::Retardant/Accelerator(name) <br /> PEDESTAL Installed By X Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width It Length R Thick in Christy Box Stove Pipe <br /> ------------ <br /> LuMP Submersible Turbine " Other HP Pump Set R 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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSAT ULAWS. <br /> I/IIN1Uly-4�U, gYANCE NOTICE REQUIRED FZ:R INSPECTIONS-PLEASE CALL(30) <br /> SIGNE .G�GG6 •-Lx%U/�'1� TITLE C-orporate SecretaEx <br /> I Ste' <br /> N <br /> DEPARTMENT USE ONLY <br /> / / t — J <br /> Application Accepted By ��Z—�� Date �x J�V Area 1 ` Employee ID* <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Amount Date Permit! Invoice# Well ID# <br /> Codes Info Remitted ice Request A <br /> G rr .7 C) L <br /> EHO4306 6/11(1019 WEU/PUMP PERMIT <br />