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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 />N-KEFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />ADDRESS 926 N Fine Rd C-IZIPLinddenn,CA 95236 <br />SSSTREET Etuird St APN09304027 PARCEL SIZE 1 -69 <br />LAND USE PPPOCATION # <br />IERNAME Wanda Centeno PHONE ��'�'�,) <br />IERADDRESS 926 N Fine Rd CITYISTATEIZJPLinden. CA 95236 <br />TRACTOR Purviance Drillers, INC PHONE209-887-3554 <br />TRACTORADDRESSP-0- Box 64 CrT'YISTATEMPLlnden CA 95236 <br />TAINT <br />TANT ADDRESS <br />k C-57 C-61 , D-09 i I Other <br />PARTY: OWNER G CONTRACTOR <br />CITYISTATEiZIP <br />NUMBER 377923 <br />Li SUBCONTRACTOR/CONSULTANT <br />PHONE <br />EXPIRATION DATE 7/31/23 <br />DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) rl DibromochloroorODane (4392) n Ar-enir Id3Q31 <br />INTENDED USE _ amestic/Private [ Irrigation/Agricultural [I Industrial ❑ Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />If different from Owner. Water System Name Contact Namy or Phone Number <br />- -- ---•• •�•• ••� �. roc Picwrnciit rvCn :1 well/ teration/Moarricavon ll Umer <br />MonitoringWell(s) #of wells '.ISoil Boring(s) #of Wrings,;Geotechnical �ofboringe <br />Out -Of -Service Well U Out -Of -Service Well Renewal D Cross -Connection Repair <br />New Pump XPumpReplacement 11 Pump Repair 7. 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 ^ Open Bottom ', Gravel Pack/Gravel Size in diameter <br />11 Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel .I Other <br />Grout Seal Depth ft Neat Cement (94 Ib bag/5 10 gal water) Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) ❑ Other <br />Grout Placement Method _i Pumped = Free Fall ❑ 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 G Stove Pipe <br />PUMP Submersible-_; Turbine C Other HP L Pump Set ( SA fl StandingWater LevelI <br />1 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 />i? t? Ar),,pAAtCF NOTrr"�-: 771= • +sF ttteso�r rinprc . v+ t A r r ,r �. <br />SIGNED' TITLE <br />• DATE '?--2/ <br />11 <br />m <br />D <br />O <br />M <br />N <br />DEPARTMENT USE ONLY <br />Application Accepted By �� Date °' I Area �I / !' CI Employee ID# <br />Grout Inspection By Date ;) SPECIAL Well Permit <br />Pump Inspection By ,'/ tom- Date2 l WAIVER Received <br />Soil Boring Inspection By r Date Constructed Well Depth ft <br />COMMENTS <br />PESC <br />Codes <br />Received Check#! Amount Permtt/ <br />InfoCash Remitted Date Service Re oast# Invoice # Well IDA <br />I, <br />L <br />Oq <br />FHnk9 <br />--Ir /-5 '^�LS�J 7C WELL /PUMP PERMIT <br />V� <br />G <br />