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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.org1ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> fn <br /> JOBADDRESS 7485 Cherokee Rd /fib cmrzlP_ Stockton,Ca m <br /> CROSS STREETA s e I v APIN y�J l� v I✓ PARCEL SIZE LANG USE APPLICATION# o <br /> A <br /> OWNER NAME Robert Freeman PHONE 209 481 5872 <br /> OWNERADDRESS 16323 E Baker Rd Cmr/STATEmP_Linden,Ca 95236 <br /> CONTRACTOR Purviance Drillers, INC PHONE 2 0 9-8 8 7-3 5 5 4 <br /> CONTRACTORADDRESSP-O- Box 64 CITY/STATE/ZIPLinden CA 95236 <br /> SUBCONTRACTORICONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CrTYJSTATFJZP <br /> LICENSE R C-57 _:C-61 ;_'D-09 7 Other NUMBER 377923 EXPIRATION DATE 7/31/21 <br /> BILLING PARTY: 1 OWNER ;i CONTRACTOR ;7 SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:C General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392)C Arsenic(4393) <br /> INTENDED USE Domesfic/Private _ rrigation/Agricultural �Industrial Water Quality Monitoring _i 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 C Replacement Well ❑Well Alteration/Modification Other <br /> (�A? I Well(s) #of wells 'i Soil BOring(s) #of borings Geotechnical #of borings <br /> Out-0f-Se 'ce Well ut OfSery ce Well Renewal Cross Connection Repair <br /> New Pum Pum Replacement um Repair C Raise Well Casing <br /> WELL CONS' TION <br /> Drilling Method ud Rotary ;Air Rotary -'Auger C Cable Tool Push Point ;7 Other <br /> Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> L'Conductor Casing In diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched 11 Steel C Plastic E 1 Stainless Steel 'I Other <br /> Grout Seal Depth ft U Neat Cement(94 1b bag/5-10 gal wafe4 r Sand Cement Sack mix/7 gal water <br /> J Bentonite(20%solids) a Other <br /> Grout Placement Method _:Pumped ❑Free Fall L Other D Retardant/Accelerator(name) <br /> PEDESTAL Installed By ^Driller L'Pump Contractor L Other <br /> Concrete Pedestal COlmensions:Width ft Length ft Thick in C;Christy Box 1-'Stove Pipe �A <br /> ❑Submersible Turbine Other HP Pump Set_kj��ft Standing Water Level ft YPIAENT <br /> 1 HEREBY CERTIFY THAT I NAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH S \/�D <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS, I ALSO CERTIFY THAT MY REQUIRED LICENSE CE'Y <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. P 15 <br /> 2020 <br /> Cea'' UR. .7VANCE NOTICE FaR INSP CTIONS-PLEASE CALL f209)9r3-769, <br /> SIGNED1G� u ..l��LL611�(� Trrt� " Dw,E /l- JOAQUIN COUNTY <br /> VIRONMENTAL <br /> Ffl TH DEPARTMENT <br /> � e <br /> e <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Area ' i' ` Employee ID# f ` <br /> Grout Inspection By Date 'I 6PECIAL Well Permit <br /> Pump Inspection By '!fin, %W l:,,r„ Date t t�' � ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Permit/ Invoice# WeIIID# <br /> Codes Info B Cash Remitted /betw Service Re uest# <br /> EHO 43-M 611112019 {� `YL \ I, I q bl '�/L WELL/PUMP PERMIT <br />