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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1865 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468.3420 <br /> NON-REFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 9420 N Hwy 88 caYaji,Stockton 95215 m <br /> CROSS STREET APN Cl r /f O` " PARCEL SIZE LAND USE APPLICATION# p <br /> z <br /> OWNER NAME Craig Formati PHOND 09-3230422 N <br /> OWNER ADDRESS 751 S 14pa thpr Dr CrrY/STATEmp Stockton CA 95207 <br /> CONTRACTOR Purviance Drillers, INC pHONE209-887-3554 <br /> CONTRACTOR ADDRESS P-O- BOX 64 CITY/STATEIZIPL i n(3en CA 95236 <br /> SUBCONTRACTORICONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CrrY/STATEMP <br /> LICENSE R C-57 _C-61 U D-09 Other NUMBER 377923 EXPIRATION DATE 7/31/21 <br /> BILLING PARTY: 1 OWNER CONTRACTOR iJ SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING:E General Mineral/Coliform Bacteria(4391) :Dibromochloropropane(4392)E Arsenic(4393) <br /> INTENDED USE DomesticlPrivate ::Inigabon/Agricuttural Ci 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 /> TYPE OF WORK D New Well n Replacement Well ;1 Well Alteration/Modification f:Other <br /> D Monitoring Wells) #of wells D Soil Boring(s) 9 of b0""gs Geotechnical s of borings <br /> D Out-Of-Service Well ❑Out-Of-Servioe Well Renewal ;.Cross-Connection Repair <br /> New Pum Pump Replacement C Pump Repair i Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method -1 Mud Rotary Air Rotary ' Auger F:Cable Tool Push Point _1 Other <br /> Proposed Well Depth ft Excavation in diameter ;I Open Bottom i�Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad Steel ❑Plastic Stainless Steel 1 Other <br /> Grout Seal Depth ft -Neat Cement(94/b bag/S-10 gal water) Sand Cement sack mixr7 gal water <br /> Bentonite(20%solids) a Other <br /> Grout Placement Method :;Pumped --Free Fall C Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller _Pump Contractor L Other <br /> -_Concrete Pedestal':Dimensions:Width ft Leng it Thick in Christy Box (1 Stove Pipe <br /> PUMP �,`Suhmersihle:'.Turbine Other HP Pump Set <br /> it Standing Water Levelft <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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> NO3iCE REQUIRED FOR INSPEC-1111" -ASE C!. <br /> I <br /> SIGNED TMEQGC LGr DATE / <br /> i <br /> I N <br /> ENT <br /> I i <br /> 0 2020 <br /> �VED <br /> d { <br /> U1 <br /> f COUNTY <br /> ` "TIENTAL <br /> qP I R T M E N T <br /> DEPARTMENT USENLY <br /> Application Accepted By � /'% Date Oa?� Area Employee ID# <br /> Grout Inspection By �rDate 1 SPECIAL Well Permit <br /> Pump Inspection By 6Cf�2C SIU Date 1 23 07 ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Recelved Check#/ Amount Permit/ <br /> Codes Info BY Cash Remitted Dat Service Re uest# Invoice# Well ID# <br /> EHD 43-06 6/77/2079 717c•/V WELL!PUMP PERMIT <br />