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t <br />WELL/PUMP PERMIT <br />r SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 4683420 <br />NON-REFUNDABLE PERMIT WWW.Sigov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />I '��e- 0, Fme- 95236 <br />JOB ADDRESS /Q�Fine Rd <br />CROSSSTREETSt Rt Hwy 26 APN. 09134029 PARCEL SIZE2.0 LAND USE APPLICATION# <br />OWNER NAME EPHONE <br />OWNERADDRESS 6601 N Fine Rd CITY/STATE/ZIP Linden,CA 95236 <br />CONTRACTOR Purviance Drillers, INC PHONE209-887-3554 <br />CONTRACTOR ADDRESS P. 0. BOX 64 CIrYlSTATEZPLinden CA 95236 <br />SUBCONTRACTORICONSULTANT PHONE <br />SUBCONTRACTORICONSULTANT ADDRESS CrrY/STATE/LP <br />LICENSE X C-57 J C-61 i D-09 D Other NUMBER 377923 EXPIRATION DATE 7/31/23 <br />BILLING PARTY: ;: OWNER D CONTRACTOR C SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: E General Mineral/Coliform Bacteria (4391) i ; Dibromochloropropane (4392) L' Arsenic (4393) <br />INTENDED USE �Domestic/Private -1 IrrigatiOn/Agricultural :7 Industrial ;; Water Quality Monitoring Li Soil Sampling/Characterization <br />D Public Water System <br />If different from Owner. Water System Name Contact Name or Phone Number <br />TYPE OF WORK C New Well D Replacement Well Well Afteration/Modification : , Other Sf <br />0 Monitoring Well(s) #of wells ❑ Soil Boring(s)4ofbodngs Of �7 Geotechnical N J ' <br />Out -Of -Service Well Out -Of -Service Well Renewal _ Cross -Connection Repair NFE7N A� <br />New Pum :Pum Re lacement iPump Repair Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method Mud Rotary Air Rotary Auger i] Cable Tool :; Push Point I Other <br />Proposed Well Depth ft Excavation in diameter -Open Bottom _Gavel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter_ in Thickness/Gauge/ASTM SchedSteel Plastic ❑Stainless Steel I Other <br />Grout Seal Depth ft C Neat Cement (94 Ib bag/5-10 gal water) C: Sand Cement sack mix/7 gal water <br />Lj Bentonite (20% solids) ❑ Other <br />Grout Placement Method Pumped J Free Fall Other Retardant / Accelerator (name) <br />PEDESTAL Installed By L Driller L Pump Contractor L Other <br />Concrete Pedestal _1 Dimensions: Width ft Length It Thick In C Christy Box -' Stove Pipe <br />P�Ma�Suhmersible�. Turbine Other HP 1 r PumpSet_��ft StandingWaterLevel 1' -JS 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 LhW9 \ <br />�,j.��r.,,.;c <br />--� K glti6'.� TITLE liflCY "`y DATE <br />DEPARTMENT USE ONLY <br />�-- T� <" <br />Application Accepted Bye rte—Date r � 1 6 1 Area i/ Employee ID# _ <br />Grout Inspection By 1 SPECIAL Well Permit <br />Pump Inspection By ate <br />F1 WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />y <br />m <br />D <br />0 <br />In <br />In <br />N <br />PE <br />Codes <br />SC Received Check#/ Amount PermiU <br />Info ash Remitted Date S ice Re # Invoice # Well ID# <br />uest <br />o -- J c <br />WELL !PUMP PERMIT <br />