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r , <br />HH'°N NSA:ti t[06 'Z '100 ;Wli paAI;3;� <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95206 - (209) 4663420 <br />NUN-KEFUNDABLE PERMIT CALL (2C 9) 953-7697 FOR INSPECTIONS EXPIRES 9 YEAR FROM DATE ISSUED <br />Jon AooREs9 17887 / V Comstock /Rd �A,1 cnyIzpLinden Ca 95236 <br />-.(I%& n l//l <br />CROSS STREET <br />i C4 r , . APN C W (Jo PARCEL SIU ([ Y • S LAND USE APPLICATION $ <br />OWNER NAME Vaccarezza Bros (Ch ri CGJAIn 4rU Pm, 209-482-4589 <br />OWNER ADDRESS 8150 N Duncan Rd cmasTATE/7IPL i n d e n CA 95236 <br />Purviance Drillers, Inc. <br />ADD,I,g P . O .Box 64 <br />"09-887-3554 <br />C1TYISTA,vw Linden, CA 95236 <br />PHONE <br />rL <br />UBCONTRACTOR ADDRESS CnY/STATEMP <br />icabisE 1 C-57 it "l L' D -D9 u Other NuilSgw 3 7 7 9 2 3 ExPIRAMON DATE <br />GEOGRAPWCALiNFORMAMON: Coordirrstes X Y Township Ranine _q If - <br />NTF-MOM USE DomesticJPrivale 1$IrdgationlAgricultural I] Industrial 0 Waterclua9tyMonitonng :r Soil SamplinglCharacledzaiion <br />Public Water System <br />I t dinemn! from Owner walerYyfflernf4axne o one <br />11 .•c r v.cu � MC:R C nnen[ "all U Well AI[erallonlModl6Cation U Other <br />i Menilaring Wef(s1 #of wells it Sol Boring(s) Pot borings I Geotechnical met6ornps <br />Out-OfSerAce Well t'I Out -Of -Semis Well Renewal r, Cross -Connection Repair <br />Drilling Method ! Mud Rotary :_ Air Rotary Auger a Cable Tool _ Push Point i I Other <br />Proposed Well Cept`I ft Excavation in diameter _ Open Bottom 0 Gravel Pack/Gravet Size in diameter <br />Conductor Casing in diameter I Conductor Casing Depth ft <br />Well Casing Diameter_ in Thidmess/Gauge/ASTM Sched :Steel a Pies, t. Sklin)ess Steel r Other <br />Grout Seal Depth ft n Neal Cement (94 lb bagn5-10 gal wafer) L• Sand Cement Sock n*d7 gal water <br />Bentonite(20%solids) n Other <br />Grout Placement Method L Pumped Free Fall C Other n Retardant i Accelerator (name) <br />PEDESTAL Installed By !I Driller G Pump Contractor r- Other <br />is Concrete Pedestal �Dimenslone: VI7!dth R Length ft Thick in _ Chrlsty Box u Stove Pipe <br />PuhIP AtSubmersible!.I Turbine a Other HP Pump Set FI Standing Wa[erLevel / it <br />I HEREBY CERTIFY THAT 1 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- 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WPTH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORENSATIO <br />MFNI 24 ANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209)953-,7697 <br />snwo TrnECorp Secretary DATE /O 3 /7 <br />y <br />r� <br />D <br />0 <br />a <br />m <br />N <br />DEPARTMENT USE ONLY GQ <br />Application Accepted BY Date 10.3"11 Area / r ( Employee ID*�f'/rn <br />Grout Inspectlon By Date °��,,,�._./�, ��_ ❑ SPECIAL Well Permit <br />Pump Inspection By Date _/ / l v5S / 13_ ] WAIVER Received <br />Soil Boring Ins ection By Date Constructed WeII apth 11 <br />COMMENTS_'O CLIQ�(( IAnt.A ���nJ.1. `L ! _ n , ,.)foil � <br />a � <br />z <br />PE <br />Codes <br />SC Received <br />Info B <br />ChecMR <br />Cash <br />Amount <br />Remitted <br />Dale <br />ermit/ (Rvolce# <br />Permit/Permit/Codes <br />Service Re uest# well 1D# <br />43Y1 <br />so <br />4i9 N " <br />£•d <br />VL5£L9960Z <br />WELL IP41MP PER IAIT <br />out saelpaQ eoueimnd dEt:tO L 6 ZO lo0 <br />