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2 <br />• WELL/PUMP PERMIT <br />t SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />NVN-KEFUNDABLE PERMIT WWW.sjgoy.org/eno tAPIKES 1 YEAR FROM DATE ISSUE <br />JOBADDRESS 4638 Green Oak Ln CITY/zip Stockton, CA 95212 <br />CROSS STREET 99 Frontacre RD APN 08521022 PARCEL SIZE 1 - 5 2 LAND USE APPLICATION # <br />OWNERNAME David MCKemey PHONE <br />OWNERADDRESs 4638 Green Oak Ln CITY/STATE/ZIPStpGkton, CA 95212 <br />CONTRACTOR Purviance Drillers, INC PHONE209-887-3554 <br />CONTRACTOR ADDRESS P- 0- Box 64 Cmr/STATEOPL i nden CA 95236 <br />SUBCONTRACTOR/CONSULTANT <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />LICENSE k C-57 ❑ C-61 ❑ D-09 a Other <br />BILLING PARTY: ❑ OWNER ❑ CONTRACTOR <br />PHONE <br />CnY/STATE/ZIP <br />NUMBER 377923 EXPIRATION DATE 7/31/23 <br />❑ SUBCONTRACTOR/CONSULTANT <br />DoMEsTIc WELL SAMPLING: 11 General Mineral/Coliform Bacteria (4391)11 Dibromochloropropane (4392) IJ Arsenic (4393) <br />INTENDED USE Domestic/Private ii Irrigation/Agricultural Industrial L Water Quality Monitoring ❑ 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 ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br />17 Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings ❑ Geotechnical # of borings <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />❑ New Pump `Pump Replacement ❑ Pump Repair ❑ Raise Well Casino <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger L, Cable Tool U Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom Cl 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 Ll Plastic ❑ Stainless Steel D Other <br />Grout Seal Depth ft ',i Neat Cement (94 lb bag/5-10 gal water) C Sand Cement sack mix17 gal water <br />Ll Bentonite (20% solids) ❑ Other <br />Grout Placement Method I I Pumped ^ Free Fall n Other [; Retardant f Accelerator (name) <br />_PEDESTAL Installed By -] Driller C Pump Contractor ❑ Other <br />❑ Concrete Pedestal ❑Dimensions: Width ft Length ft Thick in 1.1 Christy Box ❑ Stove Pipe <br />PUMP 11Submersible 7 Turbine ❑ Other HP Pump Set LA ft Standing Water Level r, <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 />c <br />DEPARTMENT USE ONLY <br />Application Accepted By Date t t <br />Grout Inspection By {' Date <br />Pump Inspection By __� Date <br />t <br />Soil Boring Inspection By Date <br />COMMENTS <br />_y <br />D <br />Area �i Employee ID# ��' �� k 67 <br />l SPECIAL Well Permit <br />7 WAIVER Received <br />Constructed Well Depth <br />ft <br />PE SC Recei ed <br />Codes Info <br />Check#/ Amount Date <br />ash Remitted <br />Permit/ <br />Service Reguest # Invoice # Well ID# <br />3F) <br />% <br />,l <br />ID 4306 6/11/2019 � / / Z) LZ I d / V 24 / WELL /PUMP PERMIT <br />