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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 />NUN -REFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 17320 E Eight Mile Rd crY2lPStocktonrCA 95212 <br />CROSS STREET_ _ Ti 1 1 v Rd APN O 91 1 6 0 0 2 PARCEL SIZE 3 4. 7 3LAND USE APPLICATION # <br />OwNERNAME _Joe Gotelli and Sons — i,e j� J (01 <br />�r7 + HONE <br />OWNERADDRESS -g'� l <br />-8_9L-NIZ-,y— Ln 12 �Y� •� �1/ CITYISTATE(ZIP Stockton CA 9 5215 S <br />CONTRACTOR Purviance Drillers, INC L. / PHONE209-887-3554 <br />CONTRACTOR ADDRESS P.O. Box 64 CITYISTATEIMPLinden CA 95236 <br />SUBCONTRACTOR/CONSULTANT <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />LICENSE k C57 '�i C-61 _1 "9 t] Other <br />BILLING PARTY: :; OWNER :: CONTRACTOR <br />CrrY/STATE/ZIP_ <br />NUMBER 377923 <br />SUBCONTRACTORICONSULTANT <br />PHONE <br />EXPIRATION DATE 7/31/23 <br />DOMESTIC WELL SAMPLING: F. General Mineral/Coliform Bacteria (4391) �l Dibromochloropropane (4392) E Arsenic (4393) <br />INTENDED USE l i DomestictPnvate rrigaton/Agricultural t: Industrial C Water Quality Monitoring l i Soil Sampling/Characterization <br />C Public Water Syst m <br />If different fmm Owner: Water System Name Contact Name cr Phone Number <br />- i rvcn L. nepid—nent well L. Well NteraDorVMoamcauon FL Other <br />Monitoring Well(s) _ #of wells --SoilBoring(s)Korborngs ' Geotechnical norborngs <br />Out -Of -Service Well Out -Of -Service Well Renewal C Cross -Connection Repair <br />;i New Pump' Pump Replacement Pump Repair f: Raise Well Czcinn <br />Drilling Method C Mud Rotary Air Rotary - Auger : Cable Tool _ Push Point Other <br />Proposed Well Depth ft Excavation in diameter a Open Bottom tl Gravel Pack/Gravel Size in diameter <br />is Conductor Casing in diameter / Conductor Casing Depth R <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched i; Steel a Plastic -I Stainless Steel t Other <br />Grout Seal Depth ft ❑ Neat Cement (94 /b beg/S-10 gel water) Sand Cement sack mixf7 gal water <br />Bentonite (20% solids) ❑ Other <br />Grout Placement Method Pumped Free Fall L'. Other C Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller C Pump Contractor L Other <br />:i Concrete Pedestal :.Dimensions: Width ft Length It Thick in C Christy Box ❑ Stove Pipe <br />PUMP SubmersibleX Turbine C Other HP a� Pump Set,ft Standing Water Level 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 1 AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />ch <br />M <br />D <br />O <br />m <br />H <br />�n / DEPARTMENT USE ONLY j <br />Application Accepted By �-1` L Z✓ Date Area Employee ID# fe11111 (7„ <br />Grout Inspection By Date L 1 -1 SPECIAL Well Permit <br />Pump Inspection By Date r I -LI )❑ WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth tt <br />COMMENTS <br />PE SC Received Checkirl Amount Permit/ <br />Codes Into sh Remitted Date Se ice Re uest # Invoice # Well ID# <br />H/1tr2pt9 /3 /Lq2— WELL /PUMP PERMIT <br />3-71 <br />F ANT <br />FO <br />� ZOZ1 <br />COO <br />T MFNT <br />