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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.sigov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOBADDRESS 6255 N Tully Rd CITymPLinden 95236 <br /> M <br /> M <br /> Baker Rd 09103014 D <br /> CROSS STREET APN PARCEL SIZE LAND USE APPLICATION# p <br /> a <br /> OWNER14AME Lawrence Sambado In <br /> PHONE In <br /> OWNER ADDRESS P.O. BOX 461 CITYISTATEmPLinden,CA 95236 <br /> C.N croK Purvianco Drillers, INC PHONE209-887-3554 <br /> CONTRACTOR ADDRESS P.O- BOX 64 CITYISTATEmPL i nden CA 95236 <br /> SUBCONTRACTORICONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE21P <br /> LICENSE k C-57 C-61 _-:D-09 ::Other NUMBER 377923 EXPIRATION DATE 7/3 1/2 1 <br /> BILLING PARTY: :OWNER _CONTRACTOR .I SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING:C General Mineral/Coliform Bacteria(4391)U Dibromochloropropane(4392)C Arsenic(4393) <br /> INTENDED US <br /> E C Domestic/Private V IrTigafion/Agricultural .i Industrial ^Water Quality Monitoring 1:Soil Sampling/Characterizafion R C� <br /> PA <br /> Public Water Syste <br /> H different from Owner Water System Name Contact Name w Plane Number <br /> TYPE OF WORK ::New Well 1:Replacement Well L Well Alterafion/Modification -1 Other �/ D <br /> ❑Monitoring Well(s) #of wells Soil Boring(s) $Of DOrt s Geotechnical N o1A N s 2020❑Out-0f-Service Well Out-Of-Service Well Renewal 11 Cross-Connection Repair S <br /> New Pum um Replacement :.Pum Repair n Raise Well Casing04 <br /> WELL CONSTRUCTION , <br /> Drilling Method .:Mud Rotary Air Rotary Auger Cable Tool C Push Point " Other ACTIN SEP FN7-ANT Y <br /> Proposed Well Depth ft Excavation in diameter -1 Open Bottom ❑Gravel Pack/Gravel Size n diameter R 47EtV j <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad :Steel ::Plastic -Stainless Steel ❑Other <br /> Grout Seal Depth ft :Neat Cement(94 lb bagl5-10 gal water) 2 Sand Cement sack mixl7 gal water <br /> u Bentonite(20%solids) ❑Other <br /> Grout Placement Method ;:Pumped ::Free Fall C Other L;Retardant/Accelerator(name) <br /> PEDESTAL Installed By r Driller C Pump Contractor G Other <br /> Concrete Pedestal^Dimensions:Width ft Length ft Thick in "Christy Box 'Stove Pipe <br /> Puu P C Submersible Turbine L Other HP L 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 I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> SIGNED \ - <br /> ..TITLE DATE <br /> G <br /> DEPARTMENT/7 USEONLY <br /> J <br /> Application Accepted By ~�'f' Date `/ 1�cT J4X U ~° f (r f, <br /> Area Employee ID# <br /> Grout Inspection By t{ Date -1 SPECIAL Well Permit <br /> Pump Inspection By 1 Date L\`18�1G+�_ 1 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#[ Amount Date Permit/Codes Info B C h Remlttad Service Request# Invoice# Well ID# <br /> EHD 43-M 6/1112019 //[,[�����7 WELL[PUMP PERMIT <br />