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s <br /> WELL/PUMP 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.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> rn <br /> JOBADDRESS 13703 E Victor Rd CITY/ZIPLOdi r CA 95240 m <br /> D <br /> CROSS STREET POR V Ln APNO 5 3 0 2 01 3 PARCEL SIZE.4 7 LAND USE APPLICATION# o <br /> OWNERNAME Christian Bailey PHONE 7l J G�Z7 <br /> OWNERADDRESS 13703 E Vi( t-nr Rd CRY/STATEIMPLindenrCA 95240 <br /> CONTRACTOR Purviance Drillers, INC PHONE209-887-3554 <br /> CONTRACTOR ADDRESS P.O. BOX 64 CITY/STATEIZIPL i nden CA 95236 <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP- <br /> LICENSE X C-57 .C-61 D-09 _Other NUMBER 377923 EXPIRATION DATE 7/31/23 <br /> BILLING PARTY: -.OWNER CONTRACTOR SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING:i General Mineral/Coliform Bacteria(4391)❑Dibromochloropropane(4392)C Arsenic(4393) <br /> INTENDED USE omesf c/Private - Irrigation/Agricultural _Industrial J 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 D New Well C Replacement Well C Well Alteration/Modification D Other <br /> D Monitoring Well(s) #ofwells I-Soil Boring(s) #of borings C Geotechnical #ofborings I�c /1''v <br /> D Out-0f-Service Well Out-Of-Service Well Renewal U Cross-Connection Repair '�D <br /> C New Pump XumpReplacement Pump Repair D Raise Well Casing <br /> WELL CONSTRUCTION l7 <br /> Drill,09 Method Mud Rotary Air Rotary -:Auger -Cable Tool -:Push Point C Other SAN <br /> Pro ed Well Depth It Excavation in diameter 7 Open Bottom - Gravel Pack/Gravel Size QU/At C <br /> .:!Conductor Casing In diameter I Conductor Casing Depth k L T M��UNTY <br /> asi Diameter_in Thickness/Gauge/ASTM Schad -_Steel ,Plastic Stainless Steel I Other A TMF <br /> 8 ut SII Depth ft --.Neat Cement(94 Ib bag/5-10 gal water) -Sand Cement sack mixf7 gal water NT <br /> .- Bentonite(20%solids) J Other <br /> Grout Placement Method Pumped Free Fall C Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller C1 Pump Contractor G Other <br /> Concrete Pedestal'Dimenslons:Width ft Length ft Thick in D Christy Box ❑Stove Pipe <br /> PUMP ubmersible-.Turbine -,Other HP Pump Seft Standing Water Level <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 COMP7LAWS. <br /> SIGNED TITLE CO 1(Vk 0tC40( DATE f,12,0 l a'( <br /> i <br /> DEPARTMENT USE N L Y ` <br /> Application Accepted By Date c> Area �l t 2 Employee ID# All 04 <br /> Grout Inspection By Date I SPECIAL'Well Permit <br /> Pump Inspection By tiA`Z{4<1,1 Date /-i i ?e' 7 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Check#/ Amount Da Permit/ Invoice# Well ID# <br /> Codes Info Cash Remitted e i Re est# <br /> FHD43-06 6/112019 130 WELL/PUMP PERMIT <br />