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WELL/PUMP PERMIT • SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAzELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 Uj ILI ` !V V MU JU�0 N i �� o NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS M a c k v i l l e Rd CITY/ZIP C1 I e m e n t s, C a 2 Z CROSS STREET Coyote Creek APN 0 0 9 1 8 0 1 1 PARCELS. Z -/ t,/trlD USE APPLICATION # OWNERNAME Eger, Gerard J & Marilyn R Trust PHONE2.09-327-9117 OWNER ADDRESS PO Box 751 CIT,/STATE/ZiP L o c k e f o r d 95237-075 CONTRACTOR 5237 - CONTRACTOR Purviance Drillers, Inc PHONE 209-887-3554 CONTRACTOR ADDRESS PO Box 64 CITY/STATE21PL i n d e n, C A 95236 SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/29P 11 (,j LICENSE C-57 U C-61 U D-09 U Other NUMBER �� EXPIRATION DATE / 3I /`�O DoNIESTIC WELL SAMPLING: C General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) :3 Arsenic (4393) NTENDED USE ❑ DomeStiC/Private 09Inigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Sal Sampling/Characterization U Public Water System It digererd from Owner. Water System Name Correct Name or Phone Number TYPE OF WoRK %New Well G Replacement Well ❑ Well Alteration/Modification ❑ Other ❑ Monitoring Well(s) # of wells ❑ Soil Borings) a or borings ❑ Geotechnical # or borings ❑ Out -Of -Service Well D Out -Of -Service Well Renewal ❑ Cross -Connection Repair F1 New PUMP F. PUMP Replacement ❑ Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method Of Mud Rotary C Air Rotary ❑ q Auger ❑ Cable Tool ❑ Push Point ❑ Other Proposed Well Depth �OOO ft Excavation ice' in diameter Al Open Bottom n Gravel Pack/Gravel Size in diameter ❑ Conductor Casing in diameter / Conductor Casing Depth it Well Casing Diameter IV in Thi ness/Gauge/ASTM Schad . 2 -SV Steel ❑ Plastic U Stainless Steel u Other Grout Seal Depth 400 it U Neat Cement (94 /b bag5-10 gal water) V Sand Cement 10-3 sack mix/7 gal water ❑ Bentonite (20% sofids) [1 Other Grout Placement Method 11 Pumped ❑ Free Fall 1) Other ❑ Retardant / Accelerator (name) PEDESTAL Installed By ^ Driller ❑ Pump Contractor ❑ Other ❑ Concrete Pedestal ❑Dimensions Width It Length it Thick in n Christy Box ❑ Stove Pipe PUMP ❑ Submersible❑ Turbine ❑ Other HP Pump Set ft Standing Water Level ft I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORK PENSATION LAWS. MINI M 2 R, DVANCE-NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209) 53- 69 SIGNE K' Tnl�orporate Secretardi10/26/17 PA TMENT U E I NLY c Application Accepted By ate Area —h* Employee ID# Grout Inspection By c Data �� fi fl SPEC AL WOII Permit Pump Inspection By Date ❑ WAIVER Received Sal Boring In action By J Date Constructed Well Depth ft COMMENTS (1 is, \ r L�1. t L(C ►t(i, EH043-06 =1/16 �CashService Request # WELL /PUMP PERMIT