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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.sigov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> ca <br /> JOBADDRESS9211 Highway 26 (ST RT 26) crrYIz,pStockton,95215 <br /> m <br /> CROSS STREET Patterson Ave APN 0 A 9(19 21 R PARCEL SIZE I -' LAND USE APPLICATION# v <br /> OWNERNAME James R. Barker PHONL209 887 3391 m <br /> OWNER ADDRESS 1305 Cooney Dr CITYISTATE21P Silver Springs,NV 89429 <br /> CONTRACTOR Purviance Drillers, INC PHONE209-887-3554 <br /> CONTRACTOR ADDRESS P-0. Box 64 CITY/STATE/MPL i nden CA 95236 <br /> SUBCONTRACTORICONSULTANT PHONE <br /> SUBCONTRACTORICONSULTANT ADDRESS CITYISTATE21P <br /> LICENSE X C-57 C-61 -1 0-09 Othef NUMBER 377923 EXPIRATION DATE 7/31/21 <br /> BILLING PARTY: OWNER ,,"i CONTRACTOR :_1 SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING:G General Mineral/Coliform Bacteria(4391)❑Dibromochloropropane(4392)C Arsenic(4393) <br /> INTENDED USE �Domestic/Private ❑laigation/Agricultural a Industrial C Water Quality Monitoring G Soil Sampling/Characterization <br /> Public Water System <br /> If different from Omer Water System Name Contact Name or Phone Number <br /> TYPE OF WORK --;New Well C Replacement Well C Well Alteration/Modification D Other <br /> _1 Monitoring Well(s) #of wells =Soil Borings) #or borings Geotechnical #of borings <br /> Out-Of-Service Well C Out-Of-Service Well Renewal L Cross-Connection Repair <br /> New Pump Pump Replacement it Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method -Mud Rotary Air Rotary '1 Auger :Cbble Tool L Push Point t] Other <br /> Proposed Well Depth ft Excavation in diameter ',]Open Bottom F!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 'I Plastic ❑Stainless Steel t I Other <br /> Grout Seal Depth ft 7 Neat Cement(94 Ib bag/5-10 gal water) Sand Cement sack mixt/9.1 water <br /> Bentonite(20%solids) ❑Other <br /> Grout Placement Method (;Pumped :,Free Fall n Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By ii Driller :Pump Contractor L' Other <br /> Concrete Pedestal'Dimensions:Width ft Length it Thick in C Christy Box F!Stove Pipe <br /> PUMP Submersible:,Turbine �,Other HP a- Pump Set 11-11 ft Standing Water Level Infl <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 I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> t ADVANCE NOi iCE REQUIRED t'O?IN ;O/NS-P1_FASE CALL f?,Ob).G 153_7697 <br /> SIGNED DATE iirr2suc- TITLE fLfQ� 619-11 • <br /> ���� � <br /> O? <br /> RFgytii <br /> AV;, <br /> Sep <br /> OFp RT04�Y <br /> MFNT <br /> --------------------------- <br /> --------------------------------------- <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date %lJJ.1�J Area /f Employes ID# f <br /> Grout Inspection By Date iJ SPECIAL Well Permit <br /> Pump Inspection By ;�L.t Date <br /> �Q(I 17�Ly ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth it <br /> COMMENTS <br /> PE SC Received Check#/ Amount Permit/ <br /> Codes Info B Cash Remitted Date Service R uest# Invoice# Well ID# <br /> EHD 43-06 6/77/2079 WELL/PUMP PERMIT <br />