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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE -STOCKTON CA 95205 -6232 (209) 468-3420 <br />1NVI4-rCtrUN1JA13Lt t'tRM1T <br />EXPIRES 1 YEAR FROM DATE <br />JOBADDRESS 12440 T1111�/ Rn CITY21PTodi,CA 95240 <br />CROSS STREET Toka y Colony Rd APN 06504013 PARCEL SIZE 9 . 5 7 LAND USE APPLICATION # <br />OWNERNAME Robert Beadles PHONE <br />OWNERADDRESS 1.2440 Tully Rd CITY/STATE/ZIPLOdi CA 95240 <br />CONTRACTOR Purviance Drillers, INC PHONE209-887-3554 <br />CONTRACTOR ADDRESS P - 0. BOX 64 CITY/STATE/ZIPL i nd en CA 95236 <br />TANT <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />LICENSE k C-57 C-61 } D-09 I i Other <br />BILLING PARTY: OWNER n CONTRACTOR <br />PHONE <br />CITYISTATEMP <br />NUMBER 377923 ExPIRATION DATE 7/31/23 <br />❑ SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: C; General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) G Arsenic (4393) <br />INTENDED USE y'Domestic/Private [ 7 Irrigation/Agricultural G Industrial : ; Water Quality Monitoring ❑ Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Owner. Water System Name Contact Name or Phone Number <br />1 YPE OF WORK ❑ New Well r; Replacement Well C Well Alteration/Modification f I Other <br />D Monitoring Well(s) # of wells C Soil Boring(s) # of borings D Geotechnical # of borings <br />❑ Out -Of -Service Well C Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />❑ New Pump Vpump Replacement C Pump Repair Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method -1i Mud Rotary -; Air Rotary L Auger Cable Tool ! Push Point Other <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom Ci Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched i Steel C Plastic [i Stainless Steel i 1 Other <br />Grout Seal Depth ft U Neat Cement (94 lb bag/5-10 gal wateo L Sand Cement sack mW7 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method a Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />(PEDESTAL Installed By L Driller E, Pump Contractor L Other <br />U Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑ Christy Box G Stove Pipe <br />PUMP Submersible.] Turbine ❑ Other HP —, /T Pump Set ci-�ib ft Standing Water Level J� 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 />.��.-- <br />C <br />Area �I n j Employee ID# 1�i ►� �� �� <br />1 SPECIAL Well Permit <br />0 WAIVER Received <br />Constructed Well Depth <br />PE SC Received Check#/ AmountPermit/ <br />Codes Info A EW Cash Remitted Dat ervice Re uest # Invoice # Well ID# <br />3Yi �1� T 7"7 ICS <br />I <br />ft <br />2_( WELL /PUMP PERMIT <br />DEPARTMENT USE ONLY <br />Application Accepted By <br />, L— Date i 1 �' �✓ 1 <br />Grout Inspection By <br />Date <br />Pump Inspection By <br />_ <br />-;b,-� Date l <br />Soil Boring Inspection By <br />Date <br />COMMENTS <br />Area �I n j Employee ID# 1�i ►� �� �� <br />1 SPECIAL Well Permit <br />0 WAIVER Received <br />Constructed Well Depth <br />PE SC Received Check#/ AmountPermit/ <br />Codes Info A EW Cash Remitted Dat ervice Re uest # Invoice # Well ID# <br />3Yi �1� T 7"7 ICS <br />I <br />ft <br />2_( WELL /PUMP PERMIT <br />