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lti "N AVEO:OI LIH Zl ';a0 auiil paAiaaa� <br />WELUPUMP PERMIT I <br />SAN JOAcum COUNTY ENYIRONUENTAL HEALTH DEPARTNENT 1668 EAST HA2SLTOM AVENUE-STOCKTON CA 9520s- (209) 4683420 <br />NUIFY-KEFUNDABLE PERMIT GALL_ (Z09) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 16788 I, Comstock Rd CITY0P L i n d e n 9 S � l F, <br />CROSS STREET b u n c a R Rd APN (' 1 �.��% PA CEL SIZE --LAND USE APPLICATtON9 <br />OwNERNAMe Raymond Avans•no PION620a-8.8703014 <br />0wNERAoDRc,a16788 E Comstock Rd CmIS'TA,- Zl-znrien Ca 95736 <br />CONTRACTOR Purviance Drillers, Inc. "09-887-3554 <br />CONTRACTOR ADDRESS P . 0. B o x 6 4 CrTYISTATEIZIP L i n d e n, C A 95236 <br />SUBCONTRACTOR PRONE <br />SUBCONTRACTOR ADDRESS CT'/STATE/ZW <br />LICEVSE K C-57 C-61 0-09 other NUMBER 31231-1_ E.LPIRATION DATE 7..131 / 1 9 <br />GEOGRAPHICALINFORMAnoN_ Coordinates X Y Township- Rance Section <br />NTSNOF-D USE ornestic/Private Irrigation/Agricultural 0 Industrial ❑ Water Quality Monitoring U Sail Sampling/Characterimflon <br />_ Public Water System <br />If dilatant from Orm_r. er am erns o s arm or ene u r <br />I rvasvvver I NeprB�erawea -, WeVAlleralronlMooificaLon Other <br />n Monitoring Wells) # of wells r' Soil Borings) a o1 em", Geotechnical . ofeoangs <br />Out -OI -Service Well ; I Out-CfSen9ce Well Renewal r: Cross -Connection Repair <br />New Pump dump Replacement _ _ Pump Repair L' Rase Well Casino <br />Drilling Method ,; Mud Rotary ._ Ali Rotary J Auger j Cabs Tool -- Push Point L. Other <br />Proposed Well Depth ft Excavatoe in diameter G Open Bottom :7 Gravel PacklGravel Size in diameter <br />:- Conductor Casing in diarieeter / Conductor Casing Depth ft <br />Wall Casing Diameter_ in ThicknesslGaugeJASTM Sched =Steel C Plastic Stainless Steel -Other <br />Grout Seal Deplh ft = Neat Cement 1'94 Ib baey5-10 gal Haler) Sand Cement sack r;W7 gal osier <br />7 Bentonite (20°% solids) r Other <br />Grout Placement Method L Pumped _ Free tall C Other Retardant / Accelerator (name) ' <br />ED TA Installed By : Drtler _ Pump Contractor 2 Other <br />I.: Concrete Pedestal L Dimensions: Width fl Lenglh ftTHck in L ChristyBoz Stove Pipe <br />PUMP X Submersible Turbine -J Other HP Pump Set ft Standing Water Level ft <br />I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPIJCATION 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 LICEME IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />INIM 24VANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209) <br />- �r!e?.r4 TIT -E `-' O r p Secretary DATE <br />PAYMENt <br />REC ED <br />1P■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■IE■■■■■■ <br />SC Received <br />Info B <br />Check* <br />ash <br />Amount <br />Remitted <br />• •; '±1��■■■■■■■■■■■■■■f■■■■■■■■■■■■■■■■■■■■I■■■■■■■ <br />Permltl <br />R uest b Invoice # Well tD4 <br />X13`6 ! <br />0 - L) <br />-'i17■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■m■■■■■■ <br />� <br />DEPARTMENT USE ONLY <br />[Date.. <br />Grout Inspection By_ <br />.. 1 Date <br />0 SPECIAL Well Permit <br />Pump Inspection By <br />n Date IL'Ii�C3 <br />WAIVER Received <br />Soil Boring Inspection By <br />._ <br />.. pUi <br />COMMENTS <br />N <br />D <br />0 <br />m <br />N <br />PE <br />Codes <br />SC Received <br />Info B <br />Check* <br />ash <br />Amount <br />Remitted <br />Date _cvioe, <br />Permltl <br />R uest b Invoice # Well tD4 <br />X13`6 ! <br />0 - L) <br />Z'd tZSCZ9860Z <br />YlEJ-L"P PERbWT <br />out saajji)Q eoueimnd e00:06 z6 Z6100 <br />