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WELLIPUMP PERMIT <br /> SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468-3420 <br /> NON-REFUNDABLE PERMIT www.sigov.org/ehd EXPIRES'I YEAR FROM DATE ISSUED <br /> JOB ADDRESS 6420 E Morada Ln Crryrbp Stockton CA 95212 m <br /> CROSSSTREET Hlldreth Ln APN PARCELSIZE 'ILI—LAND USE APPLICATION# O <br /> A <br /> OWNERNAME John BAva & Son PHON908-658-1781 N <br /> OWNERADDRESS 12022 E Comstock Rd CITY/STATEmPStockton CA 95215 <br /> CONTRACTOR Purviance Drillers, INC pHONE209-887-3554 <br /> CONTRACTOR ADDRESS P-O. BOX 64 Cm/STATE/ZIPLinden CA 95236 <br /> SUBCONTRACTORICONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATERIP <br /> LICENSE R C-57 C C-61 :!D-09 Other NUMBER 3779237/31/21 <br /> EXPIRATION DATE <br /> BILLING PARTY: %OWNER CONTRACTOR C SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:C General Mineral/Coliform Bacteria(4391)Li Dibromochloropropane(4392)E Arsenic(4393) <br /> INTENDED USE a Domestic/Private '. InigatioNAgriculturai ::Industrial L Water Quality Monitoring i:Soil Sampling/Characterization <br /> Public Water System <br /> If different from O— Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well [:Replacement Well �Well Alteration/Modification Other <br /> Monitoring Wells #of wells Soil Borin s a or bo rigsGeotechnical <br /> #or borings <br /> Out-0f-Service Well Out-Of-Service Well Renewal Li Cross-Connection Repair <br /> New Pump III Pump Replacement Pump Repair _Raise Well Casing / <br /> WELL CONSTRUCTION A �D <br /> Drilling Method _:Mud Rotary Air Rotary 71 Auger Cable Tool Push Point Other A I <br /> Proposed Well Depth It Excavation in diameter :1 Open Bottom ❑Gravel Pack/Gravel Sizejn diameter <br /> 2020 <br /> Conductor Casing in diameter / Conductor Casing Depth ft ��/JOA Q <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched Steel --'Plastic D Stainless Steel .I Othe NV/ CO <br /> Grout Seal Depth ft 7 Neat Cement(94 lb bagl5-10 gal wafer) _Sand Cement sack mix IFAA rq�N r y <br /> G Bentonite(20%solids) J Other R TM L <br /> Grout Placement Method _Pumped _Free Fall i 7 Other I Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller C Pump Contractor C Other <br /> C Concrete Pedestal:'Dimensions:Width ft Length ft Thick in -Christy Box Stove Pipe <br /> PUMP a Submersible:;Turbine ''Other HP Pump Set It 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 COMPENSATION LAWS. <br /> 4NrE N TirC1=REQUIRED F:' :DNS•PLEASE CALL f21141 93 Vin- <br /> SIGNED TITLE DATE O <br /> -T-T # <br /> DEPARTMENT USE ONLY <br /> Application Accepted ByDate �3 .�vri Area G, Employee ID# I i <br /> Grout Inspection By Date t I SPECIAL Well Permit <br /> Pump Inspection By ,1 Date �/ S��'Lc' ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount pate permit/ Invoice# Well ID# <br /> Codes Infoash Remitted Service a ue t# <br /> EHD 43-0fi 6/112019 <br /> WELL!PUMP PERMIT <br />