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JOB ADDRESS <br />CROSS STREET <br />OWNER NAME <br />8565 N Canepa Rd <br />E Malika Ct APN 08640024 <br />Joe Gotelli & Sons <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />714se-6•.- <br />PE <br />Codes <br />SC <br />Info <br />Received <br />ii <br />Amount <br />Remitted <br />4 7 ? <br />Data <br />n <br />IL 12-1 <br />Permit/ <br />Service Request # <br />LOR:014 <br />Invoice # Well ID# <br />WELL /PUMP PERMIT 4 /3 /337 <br />EHD 43-06 6/11/2019 <br />ChecIdt/ <br />rash <br />Vi <br />WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 EAST HAZELTON AVENUE - S-rocKroN CA 95205 -6232 (209) 468-3420 NON-REFUNDABLE PERMIT WWW.S ov.or /ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> CrrY/ZIP Stockton , CA 95212 <br />PARCEL Stzel 8 -84 LAND USE APPLICATION # <br />OWNER ADDRESS 9189 N Ashley Ln <br />CONTRACTOR Purviance Drillers, INC <br />CONTRACTOR ADDRESS P 0. Box 64 <br />SUBCONTRACTOR/CONSULTANT <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />CITY/STATE/ZIP <br /> PHONE <br />LICENSE k C-57 C-61 ._] 0-09 • i Other NUMBER 3 7 7 9 2 3 EXPIRATION DATE BILLING PARTY: .. OWNER ..: CONTRACTOR ..-. SUBCONTRACTOR/CONSULTANT <br />I <br />DOMESTIC WELL SAMPLING: E General Mineral/Coliform Bacteria (4391) .-- Dibromochloropropane (4392) f : Arsenic (4393) INTENDED USE r Domestic/Private Xlnigation/Agricultural -; Industrial 17 Water Quality Monitoring :_i Soil Sampling/Characterization L.: Public Water System <br />ff different from °weer. <br />TYPE OF WORK : New Well E Replacement Well E Well Alteration/Modification ; : Other i7 Monitoring Well(s) # of wells E Soil Boring(s) Cot borings <br />: Out-Of-Service Well <br /> <br /> LI O Geotechnical <br />Out-Of-Service Well Renewal L' Cross-Connection Repair <br />WELL CONSTRUCTION <br />New Pump Pump Replacement APump Repair = Raise Well Casing <br />Drilling Method - Mud Rotary = Air Rotary ... Auger .-. Cable Tool Push Point : Other Proposed Well Depth ft Excavation in diameter -I Open Bottom = Conductor Casing in diameter I Conductor Casing Depth Well Casing Diameter in Thickness/Gauge/ASTM Sched 7 Steel Grout Seal Depth ft . Neat Cement (94 lb bag/5-10 gal water) <br />: Bentonite (20% solids) D Other <br />Grout Placement Method -., Pumped = Free Fall LI Other <br />ft Thick in C Christy Box [ Stove Pipe <br />I HEREBY CERTIFY THAT I HAVE PREPARED TH <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, <br />CURRENT AND ACTIVE WITH HE CALIFORNIA <br />WORKERS COMPENS NLAWS. <br />PHONE <br />ci-rwsTATErzips t-ockton , CA 95212 <br />PHONE 209-887-3554 <br />ordsrAnizip Linden CA 95236 <br />7 /3 1 /2 3 <br />Water System Name Contact Name or Phone Number <br />C of borings <br />Gravel Pack/Gravel Size <br />ft <br />.: Plastic . Stainless Steel Li Other <br />7. Sand Cement sack mbrI7 gal water <br />in diameter <br />PEDESTAL Installed By :_i Driller C Pump Contractor E Other L: Concrete Pedestal F.DImensions: Width ft Length <br />7 Retardant / Accelerator (name) <br />PUMP SSubmersible :-I Turbine Other HP Pump Set r--3-1-0 ft Standing Water Level <br />IS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL :SS3NCIOV 3.1.1S SIGN <br /> TITLE ye.4 <br />a <br />C5 <br />EC <br />DATE <br />r— <br />k-kcAL <br /> <br />Cr'r. <br />1 <br />(C. V' <br />DEPARTMENT USE,ONLY <br />Date Cii/Vi Area L r/ Employee IDS iitj <br />Date _I SPECIAL Well Permit <br />Date A, -A" WAIVER Received <br />Date Constructed Well Depth ft