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WELL/PUMP PERMIT <br /> SAN JOAOum COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 16611 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)465-3420 <br /> NON-REFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joe ADDRESS 7485 E Cherokee cffyrzjr Stockton m <br /> D <br /> CROSS STREET Ashley Rd APN 0 8 71 8 3 4 5 PARCEL SIZE �-10 UNo USE APPLICATION# <br /> OWNER NAME Robert & Jeanie Freeman PHONE 209-481 -5872 <br /> OWNERADDREss 16323 E Baker Rd CITYMTATE21P Linden, CA 9523 <br /> CONTRACTOR Purviance Drillers, Inc PMME209-887-3554 <br /> CONTRACTOR ADDREss PO Box 64 cRY/sTATEa Linden, CA 95236 <br /> SUSCONTRACTOR/CONSULTANT n/a PHONE <br /> SUBCONTRACTORICONSULTANT ADDRESS n/a CITY/STATE/LP <br /> LICENSE V C-57 C•61 D-09 Other NUMBER3 7 7 9 2 3 EXPIRATION DATE July 31 . 1 <br /> Bum PARTY: OWNER CONTRACTOR SUBCONTRACTORICONSULTANT <br /> DoMEsnc WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392)_ Arsenic(4393) <br /> INT�o USE Domestic/Private rrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> uaeret from owner water system Name Contac Name or Phone Nuneer <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other PAYMF <br /> Monitoring Well(s) #of wells Soil Boring(s) a of b wmga Geotechnical a of borings �� A a� <br /> Out-Of-Service Well Out-0f-Service Well Renewal Cross-Connection Repair z/t'1�� <br /> New Pum Pum Replacement Pu Repair Raise Well Casin V/ <br /> WELL CONSTRUCTION V o 160 <br /> Drilling MethodMud Rota Air Rotary Auger -"C—able Tool Push Point Other 12019 <br /> Proposed Well Depth ft Excavation lq /'2- in diameter X Open Bottom Gravel Pack/Gravel Sae in dI <br /> Conductor Cjising in diameter 1 Conductor Casing Depth rt HEN Acq�)N c <br /> Well Casing Diameter 1�(Qt Thickness/Gauge/ASTM Schad r Steel Plastic Stainless Steel Omer EAL p�'1EI 7AL 7? <br /> Grout Seal Depth 2AV "' It Neat Cement(94 Ib bag15-10 gal water) Sand Cement 1043 sack mix/7 gal water gRT1yENT <br /> Bentonite(20%solids) Other <br /> Grout Placement Method XPumped - Free Fall Other Retardant/Accelerator(name) <br /> PED"TAL Instalbd By Driller Pump Contractor Other <br /> Concrete estal Dimensions:Width It Length R Thick In Civisty Box Stove Pipe <br /> PUMP Submersible Turbine Other HP Pump Set ft Standing Water Level 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. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THF, CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> OMPENSATION AWS: <br /> MI UM DVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> S TITLE Secretary DATE 11 /6/19 <br /> 0 <br /> 1 1 INC 19 <br /> DE ARTMENT USE ONLY <br /> " <br /> Application Accepted By Date a77,lt Area__jq� <br /> Employee ID# <br /> Grout Inspection ByIWO Date PECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received r 1 <br /> Soil Boring In ction By Date Constructed Well Depth S�/ R <br /> COMMENTSR� � RT A C" L�55V�1A <br /> PE SC Received I'ChNW Amount Permit/ Invoice N Well IDN <br /> Qpdes foemittedDateService R neat# <br /> a� <br /> EH043-06 6171rA1e WELL/PUMP PERMIT <br />