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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468-3420 <br /> NON-REFUNDABLE PERMIT — www.sjgov.org/ehd EXPIRES'I YEAR FROM DATE ISSUED <br /> Ln <br /> JOB ADDRESS 5403 N_ Fina Rd CITY/ZjP_Iinden 95236 m <br /> CROSS STREET APN IOS X6006 PARCEL SIZE l J n <br /> LAND USE APPLICATION# o <br /> OWNERNAME Glen Bockmon PHONE 209-292-3985 <br /> OWNERADDRESS P.O. BOX 804 CrrylSTATE/zlPLinden.Ca 95236 <br /> CONT GTpR Furviancc Drillers, INC pHONE209-887-3554 <br /> CONTRACTOR ADDRESS P.O. Box 64 CITYISTATEMPL l nden CA 95236 <br /> SUBCONTRACTOR/CONSULTANT PHONE- <br /> --SUBCONTRACTOR/CONSULTANT ADDRESS CITYISTATEIZIP <br /> LICENSE k C-57 L C-61 _D-09 Other NUMBER 377923 EXPIRATION DATE 7/31/21 <br /> BILLING PARTY: OWNER J CONTRACTOR a SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING:C General Mineral/Coliform Bacteria(4391)C Dibromochloropropane(4392)0 Arsenic(4393) <br /> INTENDED USE C Domestic/Privaterrigation/Agricultural C Industrial E Water Quality Monitoring C Soil Sampling/Characterization <br /> Public Water Syst <br /> It different from Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well L Replacement Well D Well AlterationlModification C Other <br /> Monitoring Well(s) #of wells ❑Soil Boring(s) #of borings :1Geotechnical 0 o borings <br /> Out-Of-Service Well C Out-Of-Service Well Renewal E Cross-Connection Repair <br /> New Pump Pump Replacement Kpump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary C Air Rotary G Auger Cable Tool G Push Point _ Other <br /> Proposed Well Depth ft Excavation in diameter C Open Bottom D Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad 7 Steel C Plastic C Stainless Steel J Other <br /> Grout Seal Depth ft Neat Cement(94 lb bag/5-10 gal water) 0 Sand Cement sack mix17 gal water <br /> Bentonite(20%solids) 2 Other <br /> Grout Placement Method C Pumped -1 Free Fall C Other E,Retardant/Accelerator(name) <br /> PEDESTAL Installed By :: Driller =Pump Contractor C Other <br /> Concrete Pedestal=Dimensions:Width ft Length ft Thick in is Christy Box C Stove Pipe <br /> Punic 'Submersible urbine ^_Other HP AS Pump Set / ft Standing Water Level /U"-- <br /> I <br /> I HEREBY CERTIFY THAT I AA.VE 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 /> SIGNED " W �-f����..!/z.�XGC� TITLE `�diJ ri%i7rl./. DATE <br /> I I <br /> I I I <br /> FcF���T <br /> li 1 O <br /> 9 ?020 <br /> 'A41/N C0 <br /> I pR�oNTY <br /> � Nt <br /> lilt, I <br /> I I <br /> I <br /> / J DEPARTMENT USE ONLY <br /> Application Accepted By ���L�G. Date tP��f ✓�J�v Area y A�i Employee ID# k- <br /> Grout Inspection By Date U SPECIAL Weil Permit <br /> Pump Inspection By _ C11C.-,1 (c t,_ \ Date '-I A/i. C WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth tt <br /> COMMENTS <br /> PE Sc Received Check#/ Amount Date Permit/ <br /> Codes Info Cash Remitted Service Re uest# Invoice# Well ID# <br /> EHD 63-08 8/7112079 ( I !Jl 2-3 2-- / ,�/ <br /> WELL/PUMP PERMIT <br />