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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1668 EAST HAZELTON AVENUE-STOCKTON CA 95205 -6232 (209) 468-3420 <br />NON-REFUNDABLE PERMIT www.sigov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 8801 Jacktone Rd CITY/ZIP Stn,_. kr�T 9521 5 <br />CROSS STREET Eight M i l Rd APN 0 8 91 5 0 0 9 PARCEL SIZ4 . 3 9 LAND USE APPLICATION # <br />C r`/ <br />OWNER NAME Reth (' I l I PHONE <br />am�igli <br />OWNERADDRESS P n RnX 1461 CrrYISTATE21PLockeford,CA 95237 <br />CONTRACTOR Purviance Drillers, INC PHONE209-887-3554 <br />CONTRACTOR ADDRESS P.O. BOX 64 CITYISTATEIZIPL i nden CA 95236 <br />SUBCONTRACTOR/CONSULTANT <br />SUBCONTRACTORICONSULTANT ADDRESS CITYISTATEIZIP <br />LICENSE X C-57 . C-61 _ D-09 Other NUMBER 377923 <br />BILLING PARTY: ._ OWNER : CONTRACTOR - SUBCONTRACTORICONSULTANT <br />PHONE <br />EXPIRATION DATE 7/31 /23 <br />DOMESTIC WELL SAMPLING:7 General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) C Arsenic (4393) <br />INTENDED USE Domestic/Private Orrigation/Agricultural �] Industrial Water Quality Monitoring fi Soil Sampling/Characterization <br />Public Water System <br />If different from Owner Water System Name Contact Name or Phone Number <br />TYPE OF WORK New Well rReplacement Well ❑ Well Alteration/Modification D Other <br />: Monitoring Well(s) # of wells C Soil Boring(s) # at oonngs - i Geotechnical _ # of bonngs <br />rX <br />Out-Of-Serviceell 0 Out -Of -Service Well Renewal G Cross -Connection Repair <br />Ki—, p-., ,mn , RRni—Rmant n Pumn Renair G Raise Well Casinq A <br />Drilling Method <br />-: Mud Rotary Air Rotary Auger . Cable Tool -- Push Point ❑ Other <br />DEPARTMENT USE ONLY <br />I <br />Proposed Well <br />Depth ft Excavation in diameter <br />Open Bottom Gravel Pack/Gravel Size <br />in <br />Area M Employee ID# t <br />Conductor Casing in diameter I Conductor Casing Depth ftEqLTH <br />I <br />Well Casing <br />Diameter _ in Thickness/Gauge/ASTM Schad : <br />Steel = Plastic -: Stainless Steel L; Other <br />\ <br />,^' <br />Grout Seal <br />Depth ft - Neat Cement (94 Ib bag/5-10 gal water) <br />Sand Cement <br />sack mix17 gal water <br />Date <br />= Bentonite (20% solids) -i Other <br />COMMENTS /%e <br />l �r <br />Grout Placement <br />Method J Pumped .:. Free Fall C Other <br />Retardant I Accelerator (name) <br />PEDESTAL <br />Installed By _ Driller >_ Pump Contractor L Other <br />Box <br />Stove Pipe <br />•' Concrete Pedestal '.!Dimensions: Width ft Length <br />If Thick in 7 Christy <br />= <br />PUMP <br />f.! Submersible%4Turbine -- Other HP (r <br />Pump Set I, ( g . IT Standing Water Level Gly j ft <br />1 HEREBY CERTIFY THAT I RAVE 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 />4 M,E�Nr <br />crc�Ivto <br />Q <br />2 4 2021 <br />QUIN C <br />EMEN <br />TA�NT Y <br />A�TMENT <br />PE SC I Received Check#/ Amount D to Permit/ Invoice # Well ID# <br />Codes Info ash Remitted <br />3 t 05VIEW HA 1� <br />- <br />EHD 43-06 6/112019 / WELL PUMP PERMIT <br />DEPARTMENT USE ONLY <br />I <br />�L%I <br />Application Accepted By <br />• <br />Date <br />Area M Employee ID# t <br />Grout Inspection By <br />Date <br />U SPECIAL Well Permit <br />Pump Inspection By <br />\ <br />,^' <br />Date <br />❑ WAIVER Received <br />Soil Boring In n By <br />Date <br />Constructed Well Depth ft <br />COMMENTS /%e <br />l �r <br />)�Z <br />c� <br />PE SC I Received Check#/ Amount D to Permit/ Invoice # Well ID# <br />Codes Info ash Remitted <br />3 t 05VIEW HA 1� <br />- <br />EHD 43-06 6/112019 / WELL PUMP PERMIT <br />