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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 />IYUIV-fCtYUNUAtiLt rtKNII l <br />JOB ADDRESS 8629 Robin Lane <br />CROSSSTREET Shippee Lane APN 08526011 <br />OwNERNAME Victor Gorecki <br />OWNER ADDRESS 8629 Robin Lane <br />CONTRACTOR Purviance Drillers, INC <br />CONTRACTOR ADDRESS P • O • BOX 64 <br />SUBCONTRACTORICONSULTANT <br />SUBCONTRACTORICONSULTANT ADDRESS <br />LICENSE R C-57 f' C-61 F. D-09 Other <br />BILLING PARTY: -� OWNER E'CONTRACTOR <br />1_AYIKtJ 7 TEAR FROM DATE ISSUED <br />CrrvtztP Stockton, CA 95212 <br />SIZE 1 2 LAND USE APPLICATIQN # <br />PHONE <br />CrrY/STATE/ZJP Stockton,CA 95212 <br />PHONE209-887-3554 <br />Cm/STATE21PLinden CA 95236 <br />CITY/STATE/LP- <br />NUMBER 377923 <br />i SUBCONTRACTOR/CONSULTANT <br />PHONE <br />EXPIRATION DATE 7/31/21 <br />DOMESTIC WELL SAMPLING: C General Mineral/Coliform Bacteria (4391) 11 Dibromochloropropane (4392) ❑ Arsenic (4393) <br />WENDED USE xDomestic/Private L Irrigation/Agricultural L Industrial : i 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 C New Well r: Replacement Well C Well AlterationlModification C Other <br />C Monitoring Wells) # of wells ❑ Soil Boring(s) _ of borings 0 Geotechnical # of borings <br />C Out -Of -Service Well U Out -Of -Service Well Renewal 0 Cross -Connection Repair <br />D New Pump VPUmo Replacement [; Pump Repair E Raise Well Casino <br />Drilling Method a Mud Rotary Air Rotary D Auger :1 Cable Tool Push Point Other <br />Proposed Well Depth ft Excavation in diameter :I Open Bottom U Gravel Pack/Gravel Size in diameter <br />:1 Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Schad Steel it Plastic I1 Stainless Steel ; I Other <br />Grout Seal Depth ft .] Neat Cement (941b bag/- 10 gal water) ❑ Sand Cement sack mfx/7 gal water <br />'1 Bentonite (20°% solids) D Other <br />Grout Placement Method . ; Pumped :: Free Fall I] Other :: Retardant / Accelerator (name) <br />PEDESTAL Installed By = Driller :: Pump Contractor L Other <br />Concrete Pedestal :;Dimensions: Width ft Length It Thick in ] Christy Box 0 Stove Pipe <br />PuitP XSubmersible'] Turbine . Other HP ---L— Pump Set 15 O ft Standing Water Level 1 1 It <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 />Ir "ICE NOT 107 ocnt e 7 Tr 7 a) �rrngyc c/.c r �;? 1 r n�1 ,• <br />SIGNED �•I.LGl.4Lty[ta_. TITLE �Pf�%;jG(/,1:.�. DATE •'JI'�'G'/;.I <br />DEPARTMENT USE ONLY <br />i <br />Application Accepted By v Date =� j� Area Employee ID# I ,f'1 <br />Grout Inspection By ate / 11 SPECIAL Well Permit <br />Pump Inspection By Date ❑ WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />Amount <br />Remitted <br />EHO43-09 9/71(1019 �I <br />/'� 12 �2 —7171L,0 WELL /PUMP PERMIT <br />ECEIENT <br />VED <br />aN 3 0 ?011 <br />AQUIN COUNTY <br />RDE ARTMENT <br />