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.r <br />E <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 -6232 (209) 46&3420 <br />NON-REFUNDABLE PERMIT www.sjgov.org1ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />JOBADDRESS 4570 JacktoneRd Cln'/zP Stockton,CA 95215 <br />CROSSSTREET Fairchild APN 09104013 PARCEL SIzE18. 67 LAND USE APPLICATION# <br />%� Iy1 ' <br />OWNER NAME Katicich Ranch I r�1 �r�"^Z}��"�' `--� PHONE <br />OWNER ADDRESS Q974 F Pa rrhi lrl RD CIN/STATE/ZIP Stockton, CA 95215 <br />CONTRACTOR Purviance Drillers, INC PHONE209-887-3554 <br />CONTRACTOR ADDRESS P- 0. BOX 64 Cm/STATE2tPL i nd en CA 95236 <br />SUBCONTRACTOR/CONSULTANT PHONE <br />SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP <br />LICENSE k C-57 _; C-61 D-09 : i Other _ NUMBER 377923 EXPIRATION DATE 7/ 3 1/ 23 <br />BILLING PARTY: G OWNER CONTRACTOR ; i SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: G General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) C Arsenic (4393) <br />NTENDED USE i DomestictPrivate�]t�Inigation/Agricultural i.'. Industrial 1 Water Quality Monitoring 11 Soil SamplinglCharacterization <br />Public Water Sysidm <br />If different from Owner. Water Systom Name Contact Name or Phone Number <br />TYPE OF WORK New Well - Replacement Well ❑ Well Alteration/Modification Fl Other <br />Monitoring Well(s) #of wells - Soil Boring(s) #or borings i7 Geotechnical #of borings <br />Out -Of -Service Well Out -Of -Service Well Renewal U Cross -Connection Repair <br />New Pump jl.,Pumip Replacement Pump Repair _, Raise Well Casing <br />WELL CONSTRUCTION I <br />Drilling Method Mud Rotary Air Rotary Auger Cable Tool C Push Point D Other <br />Proposed Well Depth ft Excavation in diameter I I Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched Steel "1 Plastic U Stainless Steel _ I Other <br />Grout Seal Depth ft l Neat Cement (94 lb bag/S10 gal water) j Sand Cement sack mbd7 gal water <br />Bentonite (20% solids) :1 Other <br />Grout Placement Method Pumped Free Fall tl Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal Dimensions: Width ft Length ft Thick in i,, Christy Box C; Stove Pipe <br />PUMP .;.Submersibles Turbine S Other HP Pump Set__k a 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 />rn <br />In <br />D <br />0 <br />z <br />N <br />DEPARTMENT USS ONLY <br />Application Accepted By `y�J/ —/— <br />/— Date Area Z� `l1 Employee ID# I)A_ <br />Grout Inspection By Date 11 SPECIAL Well Permit <br />Pump Inspection By Date D WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />PE SC Received Check#/ Amount Permit/ <br />Codes Info B ash' Remitted Da Service Re uest # Invoice # Well ID# <br />1 9 <br />EHD 13-06 6171120192e, WELL /PUMP PERMIT <br />