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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East HA.TELT0N AVENUE -STOCKTON CA 95205 -6232 (209)468-3420 <br />NON-REFUNDABLE PERMIT www.s • ov.or /ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 9898 E St Rt 4 <br />cfnam Stockton, CA 95215 <br />CROSS STREET KitAser RD APN18102019 PARCEL SIZE1 S 8 4 B.Akio USE APPLICATION # <br />OWNER NAME Brian Mellor <br />PHONE <br />OWNER ADDRESS P.O.Box 794 <br />CITY/STATE/21i, nden , CA 95236 <br />CONTRAcTOR Purviance Drillers, INC <br />PHONE 209-887-3554 <br />CONTRACTOR ADDRESS P.O. Box 64 cmm",mpLinden CA 95236 <br />SUBCONTRACTOR/CONSULTANT <br />PHONE <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />CITY/STATE/ZIP <br />LICENSE •k C-57 C-61 0-09 . Other NUMBER 377 9 2 3 EXPIRATION COATE 7/31/21 <br />BILLING PARTY: :1 OWNER <br />IT CONTRACTOR El SUBCONTRACTOR/CONSULTANT <br />DOMESTic WELL SAMPLING: General Mineral/Coliform Bacteria (4391): Dibromochloropropane (4392) CI Arsenic (4393) <br />INTENDED USE El Domestic/Private gationlAgricultural LI Industrial El Water Quality Monitoring LI Soil Sampling/Characterization <br />P Public Water System <br />If different from Owner Water System Name Contact Name or Phone Number <br />TYPE OF WORK El New Well II Replacement Well El Well Alteration/Modification E. Other <br />- Monitoring Well(s) ft of wells 2 Soil Boring(s) r/ of bodngs LI Geotechnical If of borings <br />_1 Out-Of-Service Well l: Out-Of-Service Well Renewal Li Cross-Connection Repair <br />L: New Pump ump Replacement Li Pump Repair :', Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method = Mud Rotary :: Air Rotary = Auger 2 Cable Tool ri Push Point it Other <br />Proposed Well Depth ft Excavation in diameter Li Open Bottom H Gravel Pack/Gravel Size in diameter <br />P Conductor Casing In diameter / Conductor Casing Depth ft <br />Well Casing Diameter In Thickness/Gauge/ASTM Sched 5 Steel 0 Plastic r! Stainless Steel EJ Other <br />Grout Seal Depth ft .- Neat Cement (94 lb bag/5-10 gal water) :: Sand Cement <br />L Bentonite (20% solids) P Other <br />Grout Placement Method _] Pumped Li Free Fall r- Other <br />PEDESTAL <br /> Installed By El Driller El Pump Contractor L: Other <br />El Concrete Pedestal [[Dimensions: Width ft Length <br />ft Thick <br />= Christy Box = Stove Pipe <br />HP ‘C-->c) Pump Set D- CIU ft Standing Water Level I Q C") ft <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 />- <br />SIGNED -1-1-41.A.Tre-A: <br />TITLE 08-(ip62c.4441 DATE CDPV/2 / <br />ST KT <br />5; <br />Retardant / Accelerator (name) <br />sack mixI7 gal water <br />PUMP SubmersibleXTurbina P Other <br />DEPARTMENT USE ONLY <br /> <br />Application Accepted By ...,- L-- L- Date /S-Al ) <br /> <br />Grout Inspection By Date 1 :I SPECIAL Well Permit <br /> <br />Pump Inspection By Date (z) / Z2-1.. il j 71 WAIVER Received <br /> <br />Soil Boring Inspection By Date Constructed Well Depth <br />COMMENTS <br />PE <br />Codes <br />SC <br />Info <br />Received Check/f! Amount <br />Remitted D ate a .. <br />Permit/ Invoice /f Well I13# <br />LB F I cps-0 WI- <br />1/ash <br />V l'a..- , *--1 7 V -It - 1- RCaljr IA 451 .1 t <br />_ ...., i .J.. <br />Area Employee IN A 67 <br />ft <br />WELL /PUMP PERMIT