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WELUPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />IV Vrv-KEhUNUAULE PERMIT www.Mgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 6181 S Mobley Rd CITY/ZIP Stockton,CA 95215 <br />CROSS STREET Bartolomei APN 18334004 PARCEL SIZEiq t{' <br />LAND USE APPLICATION # r <br />OWNER NAME Eric Johnston PHONE 'j'%3 "I"Zo,b� <br />OWNER ADDRESS 4969 West Ln CrnrISTATE0Pstockton, CA 95210 <br />CONTRACTOR Purviance Drillers, INC PHONE209-887-3554 <br />CONTRACTOR ADDRESS P - 0. BOX 64 CITY/STATE2IPL i nden CA 95236 <br />SUBCONTRACTORICONSULTANT <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />LICENSE X C-57 _ C-61 D-09 Other <br />BILLING PARTY: _ OWNER 7. CONTRACTOR <br />CITYISTATE21P_ <br />NUMBER 377923 <br />:'. SUBCONTRACTORICONSULTANT <br />PHONE <br />EXPIRATION DATE 7 / 31 / 2'; <br />DOMESTIC WELL SAMPLING: L: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) ii Arsenic (4393) <br />INTENDED USE Domestic/PrivateIrrigation/Agricultural Li Industrial -: Water Quality Monitoring LlSoil Sampling/Characterization <br />Public Water Syst m <br />If dfferanl from Ownar:Water System Name Contact Name or Phone Number <br />IYPE OF WORK J New Well C Replacement Well ,; Well Alteration/Modification -1 Other <br />Monitoring Well(s) # of wells ^ Soil Boring (s) # of borings Geotechnical # of borings <br />Out -Of -Service Well E Out -Of -Service Well Renewal ;: Cross -Connection Repair <br />Drilling Method :: Mud Rotary . Air Rotary Auger Cable Tool Push Point C Other_ <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom C Gravel Pack/Gravel Size in diameter I <br />Conductor Casing in diameter ! Conductor Casing Depth it <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched ; Steel Plastic "i Stainless Steel ! I Other <br />Grout Seal Depth ft 7 Neat Cement (94 Ib bag/5-10 gal wafer) Sand Cement_ sack mix/7 gal water <br />Bentonite (20% solids) a Other <br />Grout Placement Method - Pumped 7 Free Fall C Other Retardant / Accelerator (name) <br />PEDESTAL installed By - Driller 7 Pump Contractor L Other <br />C Concrete Pedestal .-Dimensions: Width ft Length ft Thick in Christy Box 0 Stove Pipe <br />PUMP Submersible 7 Turbine = Other HP _ Pump Sat n Standing Water Level 1'1.C7, <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 />DEPARTMENT USE ONLY <br />Application Accepted By �'� L L- Date 8'11 7 J l Area CC Employee ID# <br />Grout Inspection By Date11SPECIAL Well Permit <br />Pump Inspection By Date 101 <br />%A ZI 0 WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />PE <br />Codes <br />Codes <br />Sc Received Check#/ Amount pate Permit/ <br />Info B Cash Remitted a Re uest# Well ID# <br />31.f <br />t <br />enu 93 -UO Olt lllU'ly <br />WELL /PUMP PERMIT <br />