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{ <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKfON CA 95205 -6232 (209) 468-3420 <br />NON-REFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />JOBADDRESS 5311 N Jacktone Rd ctrrlmP Stockton. CA 95215 <br />CROSS STREET maker R ri APN 0 R 9 1 7 n 1 n PARCEL SI <br />zE1b _ 4 S LAND USE APPLICATION # <br />OWNER NAME Chia ffoo p@.n.ch..T,T C/J9tTn—nc)ndern lefty`' PHONE <br />OWNERADDRESS 1776 N Murray Rd Cm/STATE/LPLinden,CA 95236 <br />CONTRACTOR Purviance Drillers, INC PHONE209-887-3554 <br />CONTRACTOR ADDRESS P - C - Box 64 Cm./STATEmPLinden CA 95236 <br />SUBCONTRACTOR/CONSULTANT PHONE <br />SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE21P <br />LICENSE X C-57 _ C-61 D-09 ! Other NUMBER 377923 ExPIRAnoN DATE 7/31/23 <br />BILLING PARTY: _ OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: [ i General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) D Arsenic (4393) <br />INTENDED USE C Dourest GPrivate IrrigatioNAgricultural G Industrial Water Quality Monitoring r'• Soil Sampling/Characterization <br />Public Water Syst m <br />If different from Owner Water System Name Contact Nam or Phone Number <br />Li new vvee I Kepiacement well i; Well AlterationlModification D Other <br />Monitoring Well(s) #of wells L Soil Boring(s) not borings D Geotechnical tt of borings <br />D Out -Of -Service Well a Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />"' New Pump )(Pump Replacement ; Pump Repair C Raise Well Casino <br />Drilling Method _ ' Mud Rotary Air Rotary '.I Auger D Cable Tool Push Point '- Other <br />Proposed Well Depth It Excavation in diameter D Open Bottom D Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched I' Steel ❑ Plastic ; Stainless Steel I Other <br />Grout Seal Depth ft; Neat Cement (94 Ib bag/5-10 gal Water) ❑ Sand Cement sack mudir gal water <br />Bentonite (20% solids) D Other <br />Grout Placement Method S Pumped D Free Fall ❑ Other Retardant / Accelerator (name) <br />o STAL Installed By _ Driller �: Pump Contractor C Other <br />Concrete Pedestal -Dimensions: Width ft Length ft Thick in rl Christy Box " Stove Pipe <br />PUMP "] SubmersibleY'Turbine ❑ Other HP:� Pump Set IqV ft StandingWater Level tC,1Q <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 />PLEASE CALL (209) 95o-7697 <br />SIGNED TITLE lA t9 r/"/LCA(.t".t DATE I1)/2-V--- <br />PA <br />/2 <br />m <br />D <br />0 <br />FM�� r <br />cr `� ?021 <br />AQjjjfV <br />' DE PA N7q L T% <br />RTMeNT <br />_ DEPARTMENT USE ONLY 1 <br />Application Accepted By -_� L L Date L7 ✓ t ✓ Area e��.. Employee ID# <br />Grout Inspection By Date (J SPECIAL Well Permit <br />Pump Inspection By Date 7 WAIVER Received <br />I L7 <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />PE <br />Codes <br />SC Recelved Check#/ Amount <br />into Cash Remitted Date <br />PermiU <br />S rvice R nest # Invoice # Well ID# <br />FHn nvna c., n�,o <br />Lg Ir /,L57 <br />/ / /_GJ2- WELL (PUMP PERMIT <br />