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WELUPUMP PERMIT <br />SAN JOAQUI14 COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 -6232 (2091469-U71' <br />IMUN-KEFUNDABLE PERMIT www.sigov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />JOBADDRESS 14..404 St Rt- Hwy 26 CRY/ZIPLjndPnrSA _95236 <br />CROSS STREET Panning. RD APN 10502019 PARCEL SIZE A -5 -8 -LAND USE APPLICATION # <br />OWNERNAME Bi ff (Zi 1 1 i 1 and PHONE209 481 2629 <br />OWNERADDRESS 14404 St Rt Hwy 26 CrY/STATE0PT.i.,r;; r rn or,)-ic <br />CONTRACTOR Purviance Drillers, INC pHONE2 09 -8 87 - 3 5 54 <br />CONTRACTOR ADDRESS P-0- BOX 64 Cm/STATE21PLinden CA 95236 <br />SUBCONTRACTOR/CONSULTANT <br />SUSCONTRACTOWCONSULTANT ADDRESS <br />LICENSE x C-57 E C-61 D-09 a Other <br />BILLING PARTY: '_' OWNER ❑ CONTRACTOR <br />CITY/STATE/ZIP. <br />NUMBER 377923 <br />i] SUBCONTRACTOR/CONSULTANT <br />PHONE <br />EXPIRATION DATE 7/31/23 <br />DOMESTIC WELL SAMPLING: E General Mineral/Coliform Bacteria (4391) ii Dibromochloroprooana (43991 r. Arsenic 1'63031 <br />NTENDED USE Domestic/Private � Irrigation/Agricultural G Industrial Water Quality Monitoring ❑ Soil Sampling/Characterization <br />Public Water System <br />It different from Owner. Water System Name Contact Name or Phone Number <br />vvnn L. vveit ruierauonimoomcauon CI Uther <br />Monitoring Wallis) #ofwelis SoilBoring(s) #ofh0dngs Geotechnical 9 o borings <br />Out -Of -Service Well C Out-OfService Well Renewal 21 Cross -Connection Repair <br />New Pump C PumD Reolacemant `dPumn Ronnir - 0„- 1A111 <br />Drilling Method ❑ Mud Rotary _ Air Rotary _, Auger Cable Tool a Push Point L Other <br />Proposed Well Depth ft Excavation in diameter LI Open Bottom n Gravel PacWGravel Size in diameter <br />Conductor Casing In diameter / Conductor Casing Depth ft qN <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Schad I Steel D Plastic Stainless Steel D Other F <br />Grout Seal Depth ft 'l Neat Cement (94 /b bag15-10 gal water) ❑ Sand Cement sack m&7 ga <br />❑ Bentonite (20% solids) D Other <br />Grout Placement Method I Pumped D Free Fall ❑ Other 7 Retardant / Accelerator (name) <br />PEDESTAL Installed By D Driller _ Pump Contractor L Other <br />Concrete Pedestal CDimensions: Width ft Length R Thick in N Christy Box D Stove Pipe <br />PUMP Submersible{: Turbine D Other HP C Pump Set ft Standing Water Level �ft <br />I HEREBY CER IFY THAT I HAVE 'PREPAIRED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. 1 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 />DEPARTMENT USE ONLY /�� <br />Application Accepted By _ �Z— Date S� d Areaer Employee ID# <br />Grout Inspection By Date I SPECIAL Well Permit <br />Pump Inspection By Si Date <br />Cl WAVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTSDgtv;YtpJ1 �;p�iClI+L4 6' vjel► — <br />Amount <br />Remitted <br />Lov., It/?//WELL RUMP PERMIT <br />O� <br />_y <br />a <br />°o <br />ol <br />ol <br />w <br />RFq yMF <br />iP c��VF � <br />R � <br />qQ(j�S?0?2 <br />0 pgRT 4 N, -y <br />MENT <br />