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r . <br /> 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.sjgov.Orq/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 15$3a E St Rt Hwv 4 CITYZP SfocktnnrCA m <br /> a <br /> CROSS STREET Ja cktone Rd APN18313002 PARCEL SIze240.O LAND USE APPLICATION# O <br /> m <br /> OWNERNAME Mount Saint Joseph—Saint Elizabeth PHONE N <br /> OWNERADDRESS100 Masonic Ave CrTY/STATEZP San Francisco,CA <br /> CONT c,rort Purviance Drillers, INC PHONE209-887-3554 <br /> CONTRACTOR ADDRESS P-O- Box 64 Cm/STATE/zlPLinden CA 95236 <br /> SUBCONTRACTORICONSULTANT PHONE <br /> SUBCONTRACTORICONSULTANT ADDRESS CITY/STATEZP <br /> LICENSE x C-67 -C-61 - D-09 Other NUMBER 377923 EXPIRATION DATE 7/3 1/2 1 <br /> BILLING PARTY: _OWNER :;CONTRACTOR _1 SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:i,General Mineral/Coliform Bacteria(4391)❑Dibromochloropropane(4392)1-'Arsenic(4393) <br /> INTENDED USE : Domestic/Private X Irrigation/Agricuflural .Industrial ':Water Quality Monitoring 0 Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK 7:New Well 1'Replacement Well 'Well Alteration/Modification C Other <br /> i Monitoring Wells) #of wells D,Soil BOring(s) u of borings ;Geotechnical x of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement :;Pump Repair L Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary Auger [ Cable Tool Push Point _ Other <br /> Proposed Well Depth ft Excavation in diameter A Open Bottom f'.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 i I Other <br /> Grout Seal Depth ft Neat Cement(94 lb bag/5-10 gal water) Sand Cement sack mW7 gal water <br /> Bentonite(20%solids) j Other <br /> Grout Placement Method :Pumped 1;Free Fall c Other :. Retardant/Accelerator(name) <br /> PEDESTAL Installed By ::Driller _Pump Contractor L Other <br /> Concrete Pedestal:]Dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP Submersible urbine ;I Other HP \_ Pump Set_1217 ft 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. 1 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� LLu'tH�-. _ ••,TITLE .����... <br /> ^�^+ DATE <br /> F yMF <br /> or <br /> 5QUl/V <br /> C <br /> T pAR M 7'y <br /> T <br /> DEPARTMENT USE ONLY <br /> / <br /> Application Accepted By r /�- ��� Date F s U'/1W� Area Employee ID# (7 <br /> Grout Inspection By Date :D SPECIAL Well Permit <br /> Pump Inspection By Date `1.\`Z,� D WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Permitt <br /> Codes Info B Cash Remitted Date Service Reauestft Invoice# Well ID# <br /> '£i L SGL— 7 0 <br /> EHD 43-0E 8111r2019 n I�^�073 6, <br /> WELL/PUMP PERMIT <br />