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C <br />..% <br />r WELUPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />NUN-KEFUNDABLE PERMIT www.sl9ov.orglehc1 EXPIRES 1 YEAR FROM DATE ISSUED <br />JOBADDREss 20193 E St Rt Hwy 26 CFry1bP Linden,CA 95236 <br />CROSS STREETWa l l Rd APN 09130008 PARCEL SIZ6 4- 6 2 LAND USE APPLICATION # <br />OWNERNAME W -C- Potter & .Sons Inc PHONE <br />OWNERADDRESS P.O. BOX 1 509 CITY/STATE/Zip Linden,CA 95236 <br />CONTRACTOR Purviance Drillers, INC PHONE209-867-3554 <br />CONTRACTOR ADDRESS P.O. Box 64 CITY/STATEiZIPLl nden CA 95236 <br />SUBCONTRACTOR/CONSULTANT PHONE <br />SUBCONTRACTOR/CONSULTANT ADDRESS CRY/STATE2IP <br />LICENSE k C-57 C-61 D-09 Other NUMBER 377923 EXPIRATION DATE 7/31/23 <br />BILLING PARTY: F OWNER .-' CONTRACTOR [. SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: L General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) C Arsenic (4393) <br />INTENDED USE Domestic/Private E Irrigation/Agricultural E. Industrial Water Quality Monitoring G Soil Sampling/Characterization <br />Public Water System <br />if different from Owner. Water System Name Contact Name or Phone Number <br />TYPE OF WORK :: New Well C Replacement Well Well Alteration/Modification : Other <br />L <br />m <br />D <br />M <br />N <br />'�EIVFn <br />Monitoring Well(s) <br /># of wells -Soil Boringd of borings s) 'Geotechnical _ <br /># of borings <br />Out-0f-Sery ce Well - Out -Of -Service Well Renewal Cross -Connection Repair <br />Ll New Pum Pum Re lacement [; Pum Repair Raise Well Casing7 <br />��� <br />, [, 2021 <br />WELL CONSTRUCTION <br />1 <br />ENVIP <br />U(N COUNTY <br />Drilling Method "' Mud Rotary Air Rotary <br />i Auger 7. Cable Toot �: Push Point ❑ Other <br />ENTq <br />Proposed Well Depth ft Excavation <br />in diameter Open Bottom Il Gravel Pack/Gravel Size <br />in ri�t� <br />p <br />ARTMENT <br />L Conductor Casing <br />in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Schad Steel (. Plastic Li Stainless Steel U Other <br />Grout Seal Depth ft 1 Neat Cement (94 lb bag/5-10 gal water) Sand Cement Sack mW7 gal water <br />Lj Bentonfte (20% solids) '! 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 It Length ft Thick in ; Christy Box _, Stove PIPe <br />PUMP Submersibles' Turbine ❑ Other HP Pump set _ It Standinq Water Level 101 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 />DEPARTMENT USE ONLY <br />Application Accepted By �� Dateq11,11,?) Area ( ) r Employee ID# <br />Grout Inspection By Date i] SPECIAL Well Permit <br />l n <br />Pump Inspection By 7,{ o , U / Date 5M D WAIVER Received <br />Soil Boring I '�✓J�j�ctioonn By y9 Date Constructed Well Depth ft <br />COMMENTS -% 7�" (�1., i ;_} i l�".11 cl h�% <br />PE <br />Codes <br />SC Received Check#! <br />Info Cash <br />Amount Date Permit/Invoice # Well ID# <br />Remitted e e uest # <br />EHD 43-06 6/1112079 (? /, /3 / ' I —1 <br />^ Lq <br />.'�l,/t,�C/�/_ / zj---)y.( WELL /PUMP PERMIT <br />