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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1668 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468.1420 <br /> NON-REFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOBADDREss7485 E Cherokee cnyrzpStockton <br /> In <br /> Cross STREET Ashley Rd APN 08718345 PARCEL SIZE LAND USE APPLICATION# o <br /> A <br /> OWNERNAME Robert & Jeanie Freeman PH0,a09 481-5872 y <br /> OWNERADDRESS 16323 Baker Rd CITY/STATErLPLinden,Ca 95236 <br /> CONTRACTOR Purviance Drillers, INC PHONE209-887-3554 <br /> CONTRACTOR ADDRESS P.O. Box 64 CIrr/STATE/7JPLinden CA 95236 <br /> SUBCONTRACTORICONSULTANT PHONE <br /> SUBCONTRACTORICONSULTANT ADDRESS CITY/STATElAP <br /> LICENSE X C-57 : C-61 _—D-09 :Other NUMBER 377923 EXPIRATION DATE 7/31 /21 <br /> BILLING PARTY: _i OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:G General Mineral/Coliform Bacteria(4391)❑Dibromochloropropane(4392)%i Arsenic(4393) <br /> INTENDED USE DOmeStic/Private )Irrigation/Agricuhural *_ Industrial 2 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 New Well I i Replacement Well :i Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells 7 Soil Boring(s) of borings �Geotechnical a of borings <br /> Out-Of-Service Well !Out-Of-Service Well Renewal -L Cross-Connection Repair <br /> New Pump APump Replacement 7 Pump Repair -Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method '_;Mud Rotary Air Rotary _Auger Cable Tool Push Point f! Other ]jC CO <br /> Proposed Well Depth R Excavation in diameter -I Open Bottom ❑Gravel Pack/Gravel Sze ry n diameter s O <br /> Conductor Casing in diameter / Conductor Casing Depth R N J0q ?0 <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched Steel :: Plastic :I Stainless Steel :1 Other NV/ //V <br /> Grout Seal Deoth ft ;Neat Cement(94!b bag/r10 gal water) L'Sand Cement sack mixl7 I r�FN0VN <br /> Bentonite(20%solids) C Other q RTM C <br /> Grout Placement Method 'i Pumped �]Free Fall Il Other Retardant/Accelerator(name) F// <br /> PEDESTAL Installed By �i Driller _Pump Contractor C Other <br /> Concrete Pedestal!Dimensions:Width R Length ft Thick in ❑Christy Box L:Stove Pipe <br /> PUMP Submersible'Turbine :':Other HP ' /2 Pump Set R Standing Water Levelo��o R <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 /> ,EQUI?`". 70F ._ '._ry' ...7 ..--r.JC Cr't".._ =., 3j 95,,..;-�,g- <br /> SIGNED'��r!' 'L�'I-LZO�CC� TITLE C'�G LL DATE 9�� SCJ <br /> LC <br /> It <br /> O <br /> Vill <br /> L <br /> DEPARTMENT USE ONLY <br /> Application Accepted By / Date n /S Jp'J Area Employee iD# <br /> Grout Inspection By Date 1 SPECIAL Well Permit <br /> Pump Inspection By 1'L.tV:<,I If IA t_, Date it( 1 2I Lv D WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Check#/ Amount Permit! <br /> Codes Info e Cash Remitted D Service Re uest# Invoice# Well D# <br /> J" n ) <br /> EHD 43-08 elt t/2pt9 WELL/PUMP PERMIT <br />