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x <br /> A <br /> WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232 (209)465.3420 <br /> NON-REFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> Cn <br /> JOB ADDRESS 169.-; ComstockL <br /> Rd (� CITY/ZIP T.i,,rl�n rf A 95 "16 <br /> CROSS STREET Duncan Rd APN 091)(1oIo� PARCEL SIZE LAND USE APPLICATION# O <br /> A <br /> OWNERNAME GG Orachards PHONE Ya <br /> OWNERADDRESS 76815 Shi lfnn Rd CRY/STATE/Z1P_ Linden,CA 95236 <br /> CONTRACTOR Purviance Drillers, INC PHONE209-887-3554 <br /> CONTRACTOR ADDRESS P.O• BOX 64 CITYISTATEIZIPLinden CA 95236 <br /> SUBCONTRACTORICONSULTANT PHONE <br /> SUBCONTRACTORICONSULTANT ADDRESS CITYISTATE/ZIP <br /> LICENSE xC-57 DC-61 .i D-09 :'Other NUMBER 377923 EXPIRATIONDATE 7/31/21 <br /> BILLING PARTY: D OWNER C CONTRACTOR _i SUSCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING:C General MinerallColiform Bacteria(4391)❑Dibromochloropropane(4392)11 Arsenic(4393) <br /> INTENDED USE Z Domestic/Private Irrigation/Agricultural C Industrial ❑Water Quality Monitoring 7,Soil Sampling/Characterization <br /> G Public Water System <br /> ifdRerent from Owner. Water System Name Contact Nems or Phone Number <br /> TYPE OF WORK i:New Well C Replacement Well Well Alteration/Modification Other <br /> MonitoringWell(s) #of wells _Soil Boring($) xotb°nnps 7 Geotechnical /totborings <br /> Out-Of-Service Well Out-Of-Service Well Renewal :i Cross-Connection Repair <br /> New Pump !$Pump Replacement Pump Repair i i Raise Well Casing <br /> WELL CONSTRUCTION <br /> I <br /> Drilling Method - Mud Rotary :Air Rotary '7 Auger n Cable Tool -�Push Point Other <br /> Proposed Well Depth ft Excavation in diameter :I Open Bottom ❑Gravel Pack/Gravel Size in diameter <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 bag/1-10 gal Water) Sand Cement sack mix17 gal water <br /> Bentonite(20%solids) n Other <br /> Grout Placement Method o Pumped ::Free Fall G Other :1 Retardant/Accelerator(name) <br /> PEDESTAL installed By �::Driller C Pump Contractor U Other <br /> Concrete Pedestal':Dimensions:Width ft Length It Thick in _Christy Box a Stove Pipe <br /> PUMP [:Submersibl Turbine �Other HP J Z C"7 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 /> .'ANCE NOTICE QEtsUREn=11.[>jQPr.!`TlthNR-P1 ieQrG CALL fP"-g �182_�gn^ <br /> SIGNEO�""—`^"-f'"`' �t'�-e TITLE DATE Z/ <br /> pq yM <br /> q 0,9 y Fp <br /> t'-' Ro�/N ?0?1 <br /> e N�pqR cOO <br /> T <br /> L <br /> I i <br /> DEPARTMENT USE ONLY <br /> Application Accepted By LZ- Data % / Area Employee ID# <br /> Grout Inspection By ^ Date '-7 SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Permit/ <br /> Codes Info Date Cash Remitted Service Request# Invoice# Well ID# <br /> 0 ! i {! 1 <br /> EHO43-0e et'1112019 <br /> WELL(PUMP PERMIT <br />