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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1968 EAST HAzrLTON AVENUE - STOCKTON CA 95205 -6232 (209) 468.3420 <br />IMUN-KEFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 'I YEAR FROM DATE ISSUED <br />JOBADDRESS 8476 E KettlPman rn Crrr/7rPLodi.CA 95240 <br />CROSS STREET_A l p 4 ne Rrl APN 06307010 PARCEL SIZE1 . O LAND USE APPLICATION # <br />I ..1 <br />OWNERNAME Rodney Gaede PHONE <br />OWNERADDRESS 8476 E Kettleman Ln CITY/STATE2IP T.nrli -CA A5?4n <br />CONTRACTOR Purviance Drillers, INC PHONE209-887-3554 <br />CONTRACTOR ADDRESS P.O. BOX 64 CITY/STATE21PLinden CA 95236 <br />TANT <br />TANT ADDRESS <br />Clrr/STATEILP <br />PHONE <br />LICENSE X C-57 C-61 D-09 Other NUMBER 377923 EXPIRATION DATE 7/ 31 / 21 <br />BILLING PARTY: :._ OWNER CONTRACTOR L SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: f, General Mineral/Coliform Bacteria (4391) Il Dibromochloropropane (4392) ❑ Arsenic (4393) <br />NTENDED USE Domestic/Private ri Irrigation/Agricultural V Industrial C Water Quality Monitoring C S�Sampling/Characte�dzaftkon <br />D Public Water System <br />If dilterent from Owner. Water System Name contact <br />•.vrtn u t�nwvveu C maplacement wen ,: Well Alteration/MOdt ication :J Other <br />D Monitoring Well(s) # of wells 7 Soil Boring(s) * of borings C Geotechnical & or borings <br />Out -0f -Service Wellput-OfService Well Renewal G Cross -Connection Repair <br />- New Pumn '4_13umn P -1— —t P.— D-;' n o..:.... <br />Drilling Method = Mud Rotary :: Air Rotary Li Auger : Cable Toot C Push Point Il Other <br />Proposed Well Depth ft Excavation in diameter Il Open Bottom r- <br />- Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched D Steel Plastic ^ Stainless Steel t I Other <br />Grout Seal Depth ft A Neat Cement (94 ]b bag/5-10 gat water) ❑ Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) ❑ Other <br />Grout Placement Method _ Pumped Free Fall C Other Retardant / Accelerator (name) <br />PEDESTAL Installed By ; Driller –7 Pump Contractor L Other <br />Concrete Pedestal CDimensions: Width ft Length ft Thick in Christy Box L Stove Pipe <br />PUMP "' Submersible: ; Turbine v Other HP Pump Set ft Standing Water Levelft <br />1 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 />tltewmnr— RnTif.P: V;:C11ITIPP17I 1+t5^ - .,.'"MKIC _ nT NACU a ai a rnnn+, <br />m <br />D <br />O <br />m <br />rwa <br />Ftir <br />F6 <br />202, <br />DEPARTMENT USE ONLY <br />Application Accepted By '___�Z' Date % (/t Area y / .�l (/ Employee ID# <br />Grout Inspection By Date Ll SPECIAL Well Permit <br />Pump Inspection eyLZ IDate `T Ll WAIVER RBCQIVed <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />PE Sc Received Checidt/ <br />Codes Into Cash <br />Amount <br />Remitted Date <br />Permit/ <br />ervice Re uast # Invoice # Well ID# <br />I0 Vil a:—_ <br />G <br />ti C" <br />srtlreol9 <br />/ / ^, 12 2ff6 S72y 3 WELL /PUMP PERMIT <br />