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Z'd <br />Mti 'ON Wd�0:0 L106 '2ny ;JJIi paAiaaad <br />WELL/PUMP PERMIT <br />SAN JOAOUIN CWNTV ENYIRONNIENTALHEALTH DEPARTMENT 1868 EAsrHAZELTCN AVENUE-STOCKTON CASS20S - (209)468-3420 <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR IINSPECTIONS EXPIRES i YEAR FRorA DATE ISSUED <br />155 N Duncan Rd I� <br />JOSADDREss c,T.rz,P L i n d e n, C' A 9 5 2 '16 ; m <br />CROSS STREET APN16- 11 <br />PARCEL SrzETjk_2/,KtAT,,p USE�.IAPPLICATION <br />79uNER NaEE 'James A L a Q o T i o <br />PHONE. 9 U y <br />DMER ADDRE3S 155 N Duncan- Rd T-7 d C <br />CONTRACTOR Purviance Drillers, <br />c,TYrsTATFJzm <br />Ince <br />n e n, a 95236 <br />PHONE 209-887-3554 <br />CONTRACTORADDRESS P. 0_ Box 64 <br />CLTYISTATEMP <br />Linden, <br />Cz1 8523 <br />Su Bcomr;tAcrOR <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />CITY)STATElZ1P <br />LICENSE 110-57 _ C-61 I _ D-09 _ Other <br />377923 <br />7/31/1q <br />NUMBER <br />EXPIRATION DATE <br />GEOGRAPHIcALINFORMAMON: Coordinates X y <br />Tm....�F.:.. <br />.---••--•-r., .,a..ym _UDn <br />NT-rNDm USE �Oame_stirlPrivale I nigatiordAgriculhtral ' Industrial D Water Quality M04todng ❑ Soil SamptinglCharacterization <br />.. PuNic Water Syslem <br />INEPM-1 hvm Owner, ter ys em am° a ° eme or one .nicer <br />YPr Orw 1GK JNn... IAlnll <br />_ . .....a...,cmnu�rciutaomcaaan Vufer <br />Monitoring Well(s)i # of wells it Soil Boring(s) i °lbonnps r GeOteohnicat hof bni,hs <br />Out-Or_Service Wel= <br />Out -Of -Service Vyell Renewal ^Goss -Connection Repair <br />New Pum Z: Pump Re lacemenl a PUMP Re air ' Raise Well Casing <br />WEDtCONSTRUCTGN 14 75 - <br />Drilling Method mFMud Rotary Air Rotary Auger g b!e Tool _ Push Point Other <br />Proposed Well Depthfl , FxcauaLbn 144 lcf in diameter WOpen Botlom = Gravel Pack/Gravel Size in diameter <br />Conduct asm9 in dianeter I Conductor Casing Depth R <br />VJel(Casing Diameter - ice �T)- ss/GauaelAST1d Sched . ( 8J 9'Steel � Plaslic - Stainess Sleel = Other , <br />Grout Seal Depth „YSf) '7 Neat Cement (9416 6-3_15-10 gal ivate� O'S <br />Cement LD r sack rtvxl7 gal yaler <br />9entoTnile'(20%ssoo&ds) !: Other <br />Grout Placement Method *Pumped ••"s Free Fall - Other C RetardantJAcceleralor(rame) <br />PEDESTAL Installed By _ Driller r Pump ContractorOther <br />f$ Concrete Pedestal ofinensions:Widlh •ft Length flTtucl in _ChristyBox Stove Pfpe <br />Puma :_ SubmersibieL: Turbine ! [ Other HP Pump Set it Blanding V'JalerLevel ;1 <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 />WOR NSA7lON <br />@MINI 24 H V CE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />Slt:� TITLE Corporate Secrete/4/17 <br />T U E NLY <br />Application Accepted By <br />Gmut InspPxsion ByAb"q� <br />Pump Inspection By Dale <br />Soil EO&V Inspection E y Data <br />Area EmployeelD91EgarrO <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Wolf Depth ZY'7 ' ft tlrq <br />out saajji_IQ aoueyund <br />dZ£:C0 L � �0 End <br />