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tiE["N Wb' :01 LIH '0E'unr aulil paAl;�;� <br />V/ELL/PUMP PERMIT 71/ <br />SArj JoAoum COUN7YEwv1RONMENTAL HEALTH DEPARTitENT 1868 EASTHAZr Luw AVENUE-STOCKTON CA 95205 - (209)48B-3420 <br />NON-REFUNDABLE PERMIT <br />CALL 209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JDs ADDRESS 338 N Alpine <br />Permit/ InuoiceT <br />Service RequestK <br />CmIZ8 t n r k t n_._n__ �S�i�� <br />T� <br />CROSS STREET e r n <br />2 <br />iO3 0:3 %o 3 <br />(� <br />�� <br />APN <br />PARCELSI2E�IJWp U5E APPUCATION <br />7n� <br />ONNERNAME Brett Lagorio <br />� / / , <br />OHAI %OrJE209-351-1220 <br />OWNER ADDRES4 8_6_00 Tobacco <br />R d //T 7/ BE-gC44jet <br />crST.,,m, i n d e n CA 95236 <br />CONTRACTOR Purviance <br />millers, <br />Inc- PHOME 209-887-3554 <br />CONTRACTOR ADDRESS P- O- Aox <br />64 <br />CITYISTATEMP T,inden, CA 9523 <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />CIT(ISYATEIZIP <br />LICENSE X Csr _ C-61 I 009 _ other <br />NuMeeR 377923 EXPIRATION DATE 7 / 31 / i 7 <br />GEOGRAPHICALNFoRnIA'noN: Coordinates X Y Township Rance Section <br />HTENO6D Use 7 Oames6rJPrivate A Irriga GonlAgricullUral ,.,. Industrial = Wa2er Qua14y Monitoring -: SOLI Sampling/CFlarauerizafion <br />Public Water System <br />Iflur m (q Orvne1 a er em ame n e anc ar cnc umoar <br />rverr � Nepmcemenr vvrar ._ weir Ageraliortr„jodifieaLon j Other <br />Monitoring Wells) Tot vMis i-, Soil Sorin s Aar bon"r9 s <br />9() -' Geolechnica; 'ol Dorugs <br />OuL-017SerAcevvetl Out-01ServiceWel[Renewal 'Cross -Connection Repair <br />ii NEW Pump /S Pump Replaeerrenl i:S Pump Repair = Raise Weil Casing <br />Drilling Method _ hlud Rotary _Air Rotary ..:auger _Cable Tool _Push Point _ Other � <br />Proposed Well Depth R Excavaton in diameter .-: Open Botlom = Gravel PaeWGravel Size in diameler <br />Conductor Casing in diameter r Conductor Casing Depth tl <br />Well Casing Diameter_ in ThidmesslGaugeJASTMSched Sloe; Plastic Stainless Steel _ Other <br />Grant Seat Depth 9 X011 Neat Cement (114!6 ba9/5-10 gal rater) Sad Cement -sack rrrixl7 gal crater <br />Bentonite (20°A solids) ; : Other <br />G(oulPiacementrlethad Pumped -, Free Fad Other Reiardanl/Accelerator Mame) <br />PEDESTAL Installed By C Driller J Pump Contractor 17 Other <br />Concrete Pedestal Dimensions:INdlh It Length It Thiel; in , ChrislyBox - Stove Pipe <br />PUwP :_ Suh:nersibfeSVTurbine �i Other HP­ZaC1FumpSel R Standing WalerLevet 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 1.1Y REQUIRED LICENSE IS <br />CURRENT AND ACTIVE W1TH THE CALIFORNIA CONTRACTORS STATE LICENSE BDARD AND THAT I APIA IN COMPLIANCE \9rTH ALL <br />WORK_CRSCCL0PENSAT1QN LAWS. <br />IQ MINI M 24 DNCE 19 CE REQUIRED FOR INSPECTIONS -PLEASE CALL (209) 953-7697 <br />SIGNED TITLE Corporate Secret. <br />'°AY <br />?ECF �T <br />I <br />03°ou <br />PA TMENT LVSE 9NLY <br />Application Accepled By Date Am. Employee IW <br />Grout Inspection By Date I <br />1 SPECIAL Well Permit <br />Pump Inspection By _ __ Date 0 I 1 7 WAIVER Received <br />Soil Bering Inspection By Dale Constructed Well Depth h <br />COrv1MENTS <br />PE SC Received <br />Codes Info By <br />ChecW <br />Cash <br />Amount Date <br />Remitted <br />Permit/ InuoiceT <br />Service RequestK <br />WelllD <br />s� <br />(� <br />�� <br />POD 315V3 <br />I <br />-u <br />armn2 <br />C -d <br />tZSU9860Z <br />I 'I M <br />?1-.0 rPUr3 PERMr - <br />01-11 S_IB11!.IQ eOUeiAand e�9:06 Z6 00 Un(' <br />