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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)4683420 <br /> NON-REFUNDABLE PERMIT www.sjqov.oEq1ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOBADDREss 20121 Walnut Dr CITY/ZIPLinden 95236 u <br /> m <br /> CROSS STREET Wall Rd0 91 31 0 2 4 S a <br /> qpN <br /> PARCEL SIZE.�_LAND USE APPLICATION# c <br /> 0 <br /> OWNER NAME Lee Metzler Farming INC PHONE <br /> N <br /> OWNER ADDRESS 6747 Wall Rd cmdsTATEMP Linden,CA 95236 <br /> CONTRACTOR Purviance Drillers, INC PHONE209-887-3554 <br /> CONTRACTOR ADDRESS P-O. BOX 64 CaYISTATEMpLlnden CA 95236 <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTORICONSULTANT ADDRESS CITY/STATE21P <br /> LICENSE R CS7 C-61 i1 D-09 [1 Other NUMBER 377923 EXPIRATION DATE 7/31/21 <br /> BILLING PARTY: :1 OWNER L]CONTRACTOR i SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:C General Mineral/Coliform Bacteria(4391)G Dibromochloropropane(4392)C Arsenic(4393) <br /> INTENDED USE Omestic/Private D Irrigation/Agricultural C Industrial C Water Quality Monitoring I Soil Sampling�Nu.bber <br /> ization /1 <br /> C Public Water System / ' <br /> H different from Owners Water System Name Contact Name or PhonAT <br /> TYPE OFWORK C New Well C Replacement Well U / ,Well Alteration/Modification C Other 1, <br /> C Monitoring Well(s) #Of wells '_Soil Borings) #afborings J Geotechnical 9 o borings <br /> Out-Of-Service Well 1 Out-Of-Service Well Renewal ❑Cross-Connection Repair (,T <br /> C New Pump m Replacement Pump Repair L Raise Well Casing ?O�O <br /> WELL CONSTRUCTION <br /> Drilling Method :Mud Rotary C Air Rotary U Auger Cable Tool _'Push Point D Other EN Oq�` /N C <br /> Proposed Well Depth ft Excavation in diameter tl Open Bottom D Gravel PackJGravel Sizen d1 ENO LNrY <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_In Thickness/GaugelASTM Sched Steel fl Plastic ❑Stainless Steel D Other T <br /> Grout Seal Depth ft 1 i Neat Cement(94 lb bag/S-10 gal water) U Sand Cement sack rn f7 gal water <br /> D Bentonite(20%solids) L,Other <br /> Grout Placement Method D Pumped Free Fall U Other - Retardant/Accelerator(name) <br /> PEDESTAL Installed By G Driller 2 Pump Contractor C Other <br /> C Concrete Pedestal:Dimensions:Width ft Length ftThick in Christy Box D Stove Pipe <br /> PUMP ubmersible C Turbine ❑Other HP PumpSet ft Standing Water Level�tO'::J_ft <br /> I HEREBY CER IFY 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 /> ADI';U-NrE NO"WCE:RE;'1JIRrn r-G> n:G?c TSnitC na r� r. ,fit r rte c ?c <br /> TITLE DATE <br /> r <br /> cL r <br /> l DEPARTMEN�'d <br /> G <br /> Application Accepted By C/L Date 6 Area Employee IN F12 <br /> Grout Inspection By Date 0 SPECIAL Well Permit <br /> Pump Inspection By i h�j,.i i 1v 1. Date4 V i ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Permit! <br /> Codes Info B Cash Remitted Date rvice Re uest# Invoice# Well ID# <br /> $) d— 7 <br /> EH043-06 6111=19 WELL/PUMP PERMIT <br />