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y <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468342[ <br />IVLAN-KEFUNDABLE PERMIT _ www.sjqov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUES <br />JOBADDRESS 11051 E. Baker Rd CrrY21PSttockton.CA 95215 <br />CROSS STREET Ferguson Rd .�{ APN0891 3042 1 PARCEL SIZE 55. 53 LAND USE APPLICATION# <br />OWNER NAME Robert Tanaka -� I!' 11 C• n� �G 11�,r (,c7 LF PHONE <br />OwNERADDRESS 11051 E. Baker Rd ctry/sTATFlzIP Stockton,CA 95215 <br />CONTRACTOR Purviance Drillers, INC PHONE209-887-3554 <br />CONTRACTOR ADDRESS P- 0- BOX 64 CITYlSTATE2IPL i nden CA 95236 <br />SUBCONTRACTOR/CONSULTANT <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />LICENSE '� C-57 =: C-61 <br />BILLING PARTY: :11 OWNER <br />PHONE <br />CITY/STATE/Zip <br />D-09 ! Other NUMBER 377923 EXPIRATION DATE 7/31/21 <br />C CONTRACTOR C SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: E General Mineral/Coliform Bacteria (4391) G Dibromochloropropane (4392) C: Arsenic (4393) <br />INTENDED USE omestic/Private _ irrigation/Agricultural Industrial Water Quality Monitoring 7 Soil Sampling/CharactertzaGon <br />Public Water System <br />If different from Owner. Water System Name Contact Name or Phone Number <br />TYPE OF WORK 7 New Well E Replacement Well ;; Well Alteration/Modification 0 Other <br />Monitoring Well(s) #of wells Soil Boring(s) Yotlx> rigs D Geotechnical sof borings <br />t1 Out -Of -Service Well Out -Of -Service Well Renewal D Cross -Connection Repair <br />New Pump (pump Replacement Pump Repair D Raise Well Casino <br />Drilling Method :� Mud Rotary l Air Rotary E Auger i:' Cable Tool E. Push Point Other <br />Proposed Well Depth ft Excavation in diameter :] Open Bottom I I Gravel Pack/Gravel Size in diameter <br />Conductor Casing In diameter / Conductor Casing Depth ft <br />Well Casing Diameter_ in Thickness/Gauge/ASTM Sched 7 Steel r] Plastic n Stainless Steal i 1 Other <br />Grout Seal Depth ft E Neat Cement (94 /b bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) ❑ Other <br />Grout Placement Method _ Pumped :_ Free Fall L 1 Other '- Retardant I Accelerator (name) <br />PEDESTAL Installed By Driller _ Pump Contractor Other <br />Concrete Pedestal ;:Dimensions: Width ft Length ft Thick in : Christy Box E Stove Pipe <br />PUMP Submersible' -,,Turbine ::Other HP <br />Pump Set t LD Sft Standing Water Level <br />I HEREBY CE IFY 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 LAPS <br />II <br />TY� c <br />SIGN D TITLE D ` G <br />DATE <br />(n <br />m <br />D <br />M <br />m <br />N <br />■■A■■■■■■\a■■■■■■�■■■■■■■■■■■■ • . <br />■■ ■i1■■■■■■■■■■■■■■■■■■■■■■■■%21 Z-1.�1 <br />■■■■■■■■■■■■ Ems ■■■■■■■■■■■■■■■■■■■ SOMME ■■■ <br />■■■■■■■■IB■■■SEEN ■■■■■■■■■■■■■■■■■■■ ENE ■■■■■■ <br />■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ • <br />■■■■■■■■X11■■■■■■■Ems ■■■■■■■■■■■■■■■■■■■■■■■■ / <br />■■■■■■■■F7■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ EN / <br />■■■■■■■■:.■■■■ ENO ■■■■■■■■■■■■■■■■■■■■■■■■■I11an _• <br />■■■■■■■■a ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■mal■ <br />• <br />PE SC Received Check#! Amount PermlV <br />Codes I Info AIL. Cash Remitted jatl Se Ice R J�W-1 # Invoice # Well ID# <br />4 7 7.� <br />1 <br />EHn4..1-()F; RHIMIQ /1 / I _ <br />WELL /PUMP PERMIT <br />