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elk <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1M EAST HAZELTON AVENUE-STOCKTON CA 952D5 -6232 (209) 46$-3420 <br />NON-REFUNDABLE PERMIT WWW.sjgoy.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />JOBADDRESs 22024 St Rt Hwy 26 CmrZP Linden.CA 95236 <br />CROSS STREET Fine Rd APN 09134026 PARCEL SIZE 6 5 7 LAND USE APPLICATION # <br />DMER NAME GPHONE _ <br />OWNERADDRESS 175 Enterprise Ct CITY/STATEZP GaltrCA 95632 <br />CONTRACTOR Purviance Drillers, INC PHONE209-887-3554 <br />CONTRACTOR ADDRESS P -C•BOX 64 CIrY/STATEIZIPLinden CA 95236 <br />SUBCONTRACTOR/CONSULTANT <br />SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATEZP <br />LICENSE X C-57 C-61 D-09 Other NUMBER 377923 <br />BILLING PARTY: ] OWNER ❑ CONTRACTOR CI SUBCONTRACTOR/CONSULTANT <br />PHONE <br />EXPIRATION DATE 7/ 3 1/ 2 1 <br />DOMESTIC WELL SAMPLING: 1: General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) U Arsenic (4393) <br />INTENDED USE omestic/Private ❑ Irrigation/Agricultural D 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 />re yr rrvnn New Well i, Kepiacement well Well Alteration/Modification F. Other _ <br />Monitoring Well(s) # of wells D Soil Borings) # of boring' a Geotechnical # of borings <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />New Pump Pump Replacement D Pump Repair t? Raise Well Casing�q <br />WELL CONSTRUCTION r Cly <br />Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other h <br />Proposed Well Depth ft Excavation n diameter I Open Bottom U 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 :i Plastic D Stainless Steel U Other <br />Grout Seal Depth ft G Neat Cement (94 lb bag/5-10 gal water) Sand Cement sack mW7 gal water <br />Bentonite (20% solids) D Other <br />Grout Placement Method Pumped a Free Fall L Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor L Other <br />Concrete Pedestal L;Dimensions: Width ft Length ft Thick in G Christy Box '_ Stove Pipe <br />PUMP Submersible:; Turbine 7 Other HP Pump Set ft Standing Water Level ft <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 />\\^ �n ADVANCE NnTICE fZEQUI�?cn FOR !_ ISPECTIONS - P?a7AGC CALL (2T91 <br />SIGNED Y-GfAN2t+�Ci`' TITLE `(�Y'-yR'�'� DATE '57�S/ d� <br />TJ DEPARTMENT USE ONLY <br />Application Accepted By ��1747 � L Date � � ✓ � Area L1 Cf C Employee ID# <br />Grout Inspection By I SPECIAL Well Permit <br />"J A"� 7 <br />Pump Inspection By � / ate 11 WAIVER Received <br />Soil Boring Inse� o�n By Date Constructed Well Depth ft <br />COMMENTS /s.40.17 � 12-_r +/1 12 • Z7H <br />263--)0 <br />PE <br />Codes <br />SC Received <br />Info I 111n, <br />Check#! Amount Permit/ <br />Cash Remitted D to Service R # Invoice # Well ID# <br />477 <br />lz �y�o3S <br />WELL !PUMP PERMIT <br />