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WELL/PUMP 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 /> JOBADDREss 3310 N. Murray Rd CITY/ZIP Linden, 95236 a <br /> m <br /> CROSS sTREEYuncant� Rdt1� , pD <br /> APN��DA'V PARCEL SIZE LAND USE APPLICATION# p <br /> a <br /> OWNER NAME Raymond Avansino PHONE 209 887-3014 m <br /> OWNERADDRESS 1 �:;^ E Comstock CmgSTATEILPLinden,CA 95236 <br /> CONTRACTOR Purviance Drillers, INC PHONE209-887-3554 <br /> CONTRACTOR ADDRESS P-0- Box 64 CITY/STATE21PL i nden CA 95236 <br /> SUBCONTRACTORICONSULTANT PHONE <br /> SUBCONTRACTORICONSULTANT ADOREss CITY/STATE/ZIP <br /> LICENSE X C-57 C-61 .i D-09 Other NUMBER 377923 EXPIRATION DATE 7/3 1/2 1 <br /> BILLING PARTY: ;:OWNER ;7 CONTRACTOR SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING:C General Mineral/Coliform Bacteria(4391)�J Dibromochloropropane(4392)C Arsenic(4393) <br /> INTENDED USE ❑DomestiC/Pdvate -*Irrigation/Agricultural L Industrial 7 Water Quality Monitoring ❑Soil Sampling/Characterization �� <br /> Public Water System 1 <br /> If different from Owner. Water System Name Contact Name or Phone Number A ' <br /> TYPE OF WORK C.New Well Il Replacement Well C q-Well Alteration/Modification C Other I,�N <br /> Monitoring Well(s) #of wells G Soil Boring(s) #of borings 0 Geotechnical #of borings O <br /> Ci Out-Of-Service Well _'.Out-OfService Well Renewal C Cross-Connection Repair S �p ^ <br /> New Pum :Pum Replacement um Repair }-e-lk- b C Raise Well Casin 0 O20 <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary Auger C Cable Tool ❑Push Point i' Other- hFq`/'Yp C) (,+0�A' <br /> Proposed Well Depth ft Excavation in diameter i)Open Bottom ^Gravel Pack/Gravel Size in diameter AFP FN f 'r y <br /> C Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched C Steel ;: Plastic C Stainless Steel _1 Other r <br /> Grout Seal Depth ft Neat Cement(94 Ib bag/5-10 gal water) Sand Cement sack mW7 gal water <br /> C Bentonite(20%solids) ❑Other <br /> Grout Placement Method -i Pumped -Free Fall 11 Other C Retardant/Accelerator(name) <br /> PEDESTAL Installed By :Driller C Pump Contractor C Other <br /> Concrete Pedestal::Dimensions:Width ft Length ft Thick in 5 Christy Box ❑Stove Pipe <br /> PUMP C Submersibl Turbine L'Other HP�— Pump Set ft 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 I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> ADVANCE N07CE RFS?!JIM-7D FOR.11 SPF .70NS.a1 FAIS7 i^n��_ r2�c�,9F7>F(', <br /> a i _ � <br /> SIGNED -.!/J='-- � 't.L '"��- Tau L.G CA7 '4-J.vK DATE •%Jj'� <br /> V <br /> jV <br /> TH <br /> I <br /> 91E <br /> DEPARTMENT USE ONLY <br /> Application Accepted By —'0�—l--Z-- Date rl /y' ✓I- '�'� Area I �-�% Employee ID# <br /> Grout Inspection By 7 Date ❑ SPECIAL Well Permit <br /> Pump Inspection By t,!S "y Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Check#/ Amount Date Permit/ Invoice# <br /> Codes Info B sh Remitted Service Re uest# Well ID# <br /> EHD 4306 611 1r1019 WELL/PUMP PERMIT <br />