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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-KEFUNDABLE PERMITwww.sjgov.org/ehd EXPIRES 1 YEAR FROM Di <br />JOBADDRESS 4420 N Jacktone Rd Crrr/ZIpStockton,CA 95215 <br />CROSSSTREET Fairchild Rd APN09105003 PARCEL SIj 5.75 LAND USE APPLICATION# <br />OWNERNAME Vernon G Gogna Partnership-(�pry1Gt fc,r+�1V ISt7PHONE <br />OwNERADDRESS 13797 E Fanning Rd qTyISTATEmp Stock ton, CA 95215 <br />CONTRACTOR Purviance Drillers, INC PHONE209-887-3554 <br />CONTRACTOR ADDRESS P-0- BOX 64 C,TYISTATE21PL inden CA 95236 <br />SUBCONTRACTOR/CONSULTANT <br />SUBCONTRACTORICONSULTANT ADDRESS <br />LICENSE X C-57 C; C-61 [' D-09 <br />BILLING PARTY: OWNER <br />PHONE <br />TE <br />CITYISTATEIZIP <br />Other NUMBER 377923 EXPIRATION DATE 7/ 31 / 21 <br />CONTRACTOR ;; SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: t: General Mineral/Coliform Bacteria (4391) C Dibromochloropropane (4392) C Arsenic (43931 <br />I TENDED USE ; Domestic/Private >IrrigationlAgricultural [] Industrial E Water Quality Monitoring I' Soil Sampling/Characterization <br />Public Water System <br />If different from Owner. Water System Name Contact Name or Fhona Number <br />i.cw vvcu rtepiacement wen ,; well Alteration/Modification D Other <br />MonitoringWell(s) #of wells ❑SoilBoring(s) #of borings )Geotechnical 9 o borings <br />Out -0f -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />Ncw P'. D....,.. De..I.,,.e.,,,...a .,f o....._ o --- ._ .. - .., .... <br />Drilling Method c Mud Rotary :; Air Rotary D Auger a Cable Tool ❑ Push Point 11 Other <br />Proposed Well Depth ft Excavation in diameter I Open Bottom D Gravel Pack/Gravel Size in diameter <br />t: Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Schad D Steel D Plastic n Stainless Steel :J Other <br />Grout Seal Depth ft - Neat Cement (94/b bag/5-10 gal water) ❑ Sand Cement sack mixl7 gal water <br />Bentonite (20% solids) D Other <br />Grout Placement Method Pumped - Free Fall C Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller L; Pump Contractor G Other <br />C Concrete Pedestal LIDlmensions: Width ft Length ft Thick in " Christy Box ; Stove Pipe <br />PUMP ' : Submersible- -Turbine Other HP f Pump Set�' Ci ft Standing Water Level _ ,-r i 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 I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />M <br />D <br />O <br />m <br />N <br />DEPARTMENT USE ONLY <br />�j / / .� <br />Application Accepted By rI% � LCL- Date I� /i Area (1 (i Employee ID# DA <br />Grout Inspection By Date r) SPECIAL Well Permit <br />Pump Inspection By _ �L + t Date i Z z 7 WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth g <br />COMMENTS <br />PE <br />Codes <br />SC Received Check#/ Amount Permit/ <br />Info ash Remitted Da[ Servlce uest# Invoice# WellID# <br />� � - - <br />C&4.'—R- <br />& /./—R- /2S / 7� j WELL /PUMP PERMIT <br />