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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.sigov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOBADDRESS 9140 Pezzi Rd CITYrzIP Stockton,Ca95215 m <br /> �7a�c qQ✓042 '/ D <br /> CROSS STREET _ 11/U �`.ti. APN Q,� / 1 PARCEL SIZE LAND USE APPLICATION# o <br /> X <br /> OWNER NAME Bill Jeffery PHONE209-981-3580 y <br /> OWNER ADDRESS9140 Pezzl Rd CITY/STATE/ZIP Stockton,Ca 95215 <br /> CONTRACTOR Purviance Drillers, INC PHONE209-887-3554 <br /> CONTRACTOR ADDRESS P-D- Box 64 CrTY/STATE/Z1PLinden CA 95236 <br /> SUBCONTRACTORICONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP <br /> LICENSE k C-57 CI C-61 -:D-09 C Other NUMBER 377923 EXPIRATION DATE 7/3 1/2 1 <br /> BILLING PARTY: -OWNER -CONTRACTOR 1: SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING:G General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392)L:Arsenic(4393) <br /> INTENDED USE KDomestic/Private E IrrigaGoNAgricultural -Industrial L Water Quality Monitoring :,Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well C Replacement Well -Well Alteration/Modification Other M�' <br /> _7 Monitodn Wells #of wells _Soil Boring(s)s #of borings z or borings ' <br /> 9 O gO -Geotechnical <br /> J Out-Of-Service Well C Out-Of-Service Well Renewal E.Cross-Connection RepairO <br /> New Pum Pum Replacement t;Pum Repair Raise Well Casing <br /> WELL CONSTRUCTION Lu, 1 <br /> Drilling Method Mud Rotary C Air Rotary _Auger Cable Tool E Push Point -, Other S4 IV <br /> / ?020 <br /> Proposed Well Depth ft Excavation in diameter U Open Bottom f 1 Gravel Pack/Gravel Size COO <br /> Conductor Casing in diameter / Conductor Casing Depth ft TH SEP NlV T y <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched Steel _I Plastic :'.Stainless Steel Other T� <br /> Grout Seal Depth It _1 Neat Cement(941b bagl5-10 gal water) Sand Cement sack mixf7 gal water FNT <br /> =Bentonite(20%solids) D Other <br /> Grout Placement Method Pumped _Free Fall L Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By _Driller Pump Contractor L Other <br /> Concrete Pedestal_Dimensions:Width It Length ft Thick in Christy Box ,Stove Pipe <br /> PUMP ubmersible:.Turbine ::Other HP Pump Set It Standing Water Level \ 3 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 /> DVANCE NOTICE REMIT--:— FOR2t SPE(:TIONS-PLEASE CA' 99)953-7F_--- <br /> SIGNED \. /Qd.C,O�� JI1LI.7r��J TITLE DATE �a— <br /> ID <br /> I � <br /> IY <br /> l <br /> �- <br /> I <br /> � I <br /> � I I <br /> ll DEPARTMENT USE ONLY <br /> Application Accepted By GSL Date 3 ova b Area Employee ID# <br /> Grout Inspection By Date -1 SPECIAL Well Permit <br /> Pump Inspection By tiervt0 is l _�y Lif_Date 1112A+L Sit 1 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permit/ invoice# Well ID# <br /> Codes Info Cash Remitted Service Re uest# <br /> �13d1' oS0 X77 �i 2v I `` <br /> t <br /> EHO43-06 61112019 7 ` J�{j+/\ WELL/PUMP PERMIT <br /> /134�?t/� lJ V <br />