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WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 186E EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)4683420 <br /> NON-REFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOBADDRESS 21921 E. St Rt Hwy 4 <br /> CITY/Zip_ Stockton,CA m <br /> CROSS STREETHpuli t t RC1 APN 1$���(L2 S PARCEL SIZE 1 ,I LAND USE APPLICATION# p <br /> z <br /> OWNERNAME Chad Davis PHONE N <br /> OWNERADDRESS 21921 E St Rt Hwy 4 CITY/STATE/ZIPStQckton.CA 95215 <br /> CONT?tAGTOR Purviance Drillers, INC PHONE209-887-3554 <br /> CONTRACTOR ADDRESS P.O. BOX 64 CITY/STATE/ZIPLinden CA 95236 <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTORICONSULTANT ADDRESS CITYISTATE/ZIP <br /> LICENSE X C-57 _:C-61 .1 D-09 7,Other NUMBER 377923 EXPIRATION DATE 7/31/21 <br /> BILLING PARTY: 7 OWNER ❑CONTRACTOR [: SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:G General Mineral/Coliform Bacteria(4391)!Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE Domestic/Private 1.1 Irrigation/Agricultural Industrial "Water Quality Monitoring 11 Soil Sampling/Characterization <br /> E Public Water System <br /> If different from Owner. Water System Name Conlacl Name or Phone Number <br /> TYPE OF WORK C New Well U Replacement Well [7 Well Alteration/Modification Other <br /> Monitor Wells #of wells ❑Soil Borin s #of borings #of bons / <br /> Monitoring ( ) 9( ) El Geotechnical g �, <br /> Out-Of-ServicePumpWell D Out-OfService Well Renewal i i Cross-Connection Repair �D <br /> New Pum Pum Replacement um Repair Raise Well Casing <br /> WELL CONSTRUCTION U <br /> Drilling Method ---Mud Rotary ;Air Rotary �Auger' D Cable Tool i�Push Point Other 2 O 2910 <br /> Proposed Well Depth ft Excavation in diameter :I Open Bottom t!Gravel Pack/Gravel Size <br /> Conductor Casing in diameter 1 Conductor Casing Depthft N ENV)R O/N Co y <br /> Well Casing Diameter_in Thickness[Gauge/ASTMSchad Steel D Plastic [i Stainless Steel D Other SALT N/v1EN7A NTY <br /> Grout Seal Depth ft :Neat Cement(941b bag/S-10 gal water) Sand Cement sack mix/7 gal water pART/v]FN' 1 <br /> Bentonite(20%solids) D Other J <br /> Grout Placement Method _i Pumped 2 Free Fall L Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By -Driller E Pump Contractor D Other <br /> C Concrete Pedestal DDimensions:Width ft Length ft Thick in El Christy Box Stove Pipe <br /> PUMP Submersible':Turbine 2 Other. HP—'3 Pump Set 18 ft Standing Water Level 157J ft <br /> 1 HEREBY CERT 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 /> .,,rn Nl?;^rvn^+I+ ��n,!I t -=?'�'•'r^i� ...,+�^ r• �:r_��F-t-'.o <br /> SIGNED .,.TITLE <br /> DATE ^�©1Z.3/JI KJ <br /> 7 <br /> i <br /> DEPARTMENT USE ONLY r <br /> Application Accepted By Date 0 a7 0Zb Area Employee 10# 1 <br /> Grout Inspection By l Date D SPECIAL Well Permit <br /> Pump Inspection By .v L.S\� Cti 1, k`w,L Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Check#1 Amount Pe it/ <br /> Codes Info Cash Remitted Date Service Re uest# Invoice# Well ID# <br /> -�3 0S0 <br /> EHD C3-O6 6/17/2079 �/I�- Y WELL lPUh1P PERMIT <br />