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WELUPUMP PERMIT <br />1 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCFCTON CA 95205 -6232 (209) 468-3420 <br />INUIN-KEFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES i YEAR FROM DATE ISSUED <br />JOB ADDRESS 4304 N ,TarktnnP Rrl CITY21PStockton, CA 95212 <br />CROSS STREET Ea i rch i 1 r] rC1 APN 0 91 Q-5()()4 PARCEL SIZE 2 1 . 3 SLAND USE APPLICATION # <br />OWNER NAME Vernon G Gogna PartenerShlp _ PHONE209 603 0011 <br />OWNER ADDRESS I-3'is 1E Panning RC1 CIN/STATE/ZIPStockton, CA 95212 <br />CONTRACTOR Purviance Drillers, INC PHONE209-887-3554 <br />CONTRACTOR ADDRESS P.O. BOX 64 CIN/STATE/ZIPL1nden CA 95236 <br />SUBCONTRACTOR/CONSULTANT <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />CITY/STATE/ZIP <br />PHONE <br />LICENSE x C-57 _: C-61 ::: D-09 Other _ NUMBER 377923 EXPIRATION DATE 7/31/23 <br />BILLING PARTY: ._ OWNER a CONTRACTOR _i SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: I General Mineral/Coliform Bacteria (4391) (i Dibromochloropronane (4392) i Arsenir- (4393) <br />NTENDED USE .)rpomestic/Private Irrigation/Agricultural _ Industrial D Water Quality Monitoring ;-: Soil Sampling/Characterization <br />'Public Water System <br />If diHerenL from OWner. Water System Name Contact Name or Phone Number <br />.— o mupidcement vven wen Alteration/MI ;. Other <br />Monitoring Well(s) #of wells F� Soil Borings) Oofborings Geotechnical #ofborings <br />0 Out -Of -Service Well ❑ Out -Of -Service Well Renewal Cross -Connection Repair <br />D New Pump Pump Replacement ❑ Pump Repair Raise Well Casinn <br />Drilling Method _: Mud Rotary : Air Rotary ._ Auger _: Cable Tool , Push Point Other <br />(Proposed Well Depth ft Excavation --in diameter 11 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 Schad . Steel Plastic i Stainless Steel t] Other <br />Grout Seal Depth ft Neat Cement (94 lb bag/5-10 gal water) Sand Cement sack m/x17 gal water <br />! Bentonre (20% solids) Other <br />Grout Placement Method Pumped Free Fall C Other Retardant / Accelerator (name) <br />PEDesTAL Installed By _ Driller :Pump Contractor I:. Other <br />Concrete Pedestal .Dimensions: Width ft Length <br />it Thick in Christy Box ^Stove Pipe <br />'.PUMP Submersible.. Turbine '.-; Other HIP Pump Set ft Standing Water Level (,(n 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 I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />m <br />m <br />O <br />A <br />N <br />DEPARTMENT USE ONLY <br />ZApplication Accepted By Z_" Date S �%� ti Area 1 Employee ID# Ff-rvnk <br />Grout Inspection By —A A j Date �I I SPECIAL Well Permit <br />Pump Inspection By ,/ Date ) 1 Z Z L 1 WAIVER Received <br />Soil Boring Inspection By at QQ Constructed Well Depth — ft <br />COMMENTS b J i ' "VI N ( l •( I Yr r' "t l fri 1– V�/7 3i �1 �_ <br />PE <br />Codes <br />Sc Received <br />Info V. <br />Check#/ <br />Cash <br />Amount Permit/ <br />Remitted Dat Service Re uest # Invoice # Well ID# <br />q3$i <br />0-C)P-7 <br />1 <br />EH043-06 <br />6111!2019 <br />WELL /PUMP PERMIT <br />MENr <br />Ep <br />5 2022 <br />E a4NTy <br />L <br />'4 RMENT <br />