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WELL/PUMP PERMIT <br />* SAV JOAQUIN COUNTY ENvINDNNENTAL HEALTH DEPARTMENT 1668 EAST HAZELTON AvErvUE - STOCKTRN CA 95205 - 1209) 488342( <br />r <br />0 <br />PAN <br />RECEIV I <br />i NAV 14 <br />y.,t ,}DAQUIM <br />EK �RONM <br />H�-TM DEW <br />NON-REFUNDABLE PERMIT/Li. CALL (209) 963-7897 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />J08AnoREss 23709/Brandt rdCITY/z,PLodi CA 95240 <br />CRoss $TREETA c a m e o R d A423-170-08 PARCELS.* W LANG USE APPL]CAMN # <br />OMERNAME SKS Enterprises PHON,20C)-986-1314 <br />OWNER ADDRESS 2'1 :7 () g B r a a d t R d CITYiSTATE/72P L o d i CA 95240 <br />CONTRACTOR Purviance Drillers, Inc PH,,E 209-887-3554 <br />CONTRACTaR ADDREss P-0 Box 64 CrrY/STATEMPL i ad e n, C, A 95236 <br />PHONE <br />M ADDRESS CITY/STATE/LP <br />C57 0 C-61 ❑ D-09 Ll Other NUntatat 3 7A%) 3 EXP7RATIOx DATE ' <br />DOMESTIC WELL SAMPLING: ❑ General ineral/Coliform Bacteria (4391) C Dibromochloropropane (4392) 3 Arsenic (4393) <br />NTENDED USE 0 DOMesllclPrivate Irrigalion/Agricultural G Industrial ❑ yYater Cluality Monitoring ❑ Soil Sempling/Charac erization <br />❑ Pudic Water System <br />If ditterem ham Owner. Water S"fem Name COPM01 Name or Prone Number <br />I YPE OF WORK ❑ New Weil G Replacernent Weil 0 V{ell Alteration/ribettication J Other <br />D Monitoring Wells) * of wells G Soil Boring(s) ambodngs r; Geotechnical _ <br />7 Out -Of -Service Well L OuI-0E-Service Well Renewal ❑ Cross. -Connection Reoair <br />Q <br />f or borings <br />Drilling Method 3 Mud Rotary ❑ Air Rotary n Auger D Cable Tool ❑ PLsli Paint ❑ Other <br />Proposed Well Depth ft Excavation in diameter Open Bottom 0 Gravel Pack/Gravei Sizein d1ameer <br />U Conductor Casing .n diameter I Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched ❑ Steel D Plastic G Stainless Steel D Omer <br />Grout Seal Depth ft J Neat Cement (94 lb bagrS-lagal water) ❑ Sand Cement sack aixn gal water <br />D Benlanite (20% solids) 0 Other <br />Grout MacemenlMethod 0 Pumped 0 Free Fall 0 Other ❑ RetardanllAccelerator(name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal 11Dlmensions: VAdth R Length it ThIck in ❑ Christy Elox '3 Stove Pip. <br />PUNP <10 Sl2)mersi Turbine 0 Other HP-IT-12—Pump Sel ft Standing Water Level � (O <br />1 HEREBY CERTI AT AVE 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 15 <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />SIGNED <br />Application Accepted By <br />Grout I nspecdDn By <br />Pump Inspection By <br />Sal Boring Inspection By <br />COMMENTS <br />ANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 i <br />zos, n,r Orporate SecretarlyATE <br />.b <br />DE[AR TMENTSI- N L Y <br />Date t,L 1 <br />Date <br />Date "I I fit <br />Dale <br />Area- "l_Employee I <br />❑ SPECIAL Well PWMit <br />❑ WAIVER Received <br />Constructed Well Depth <br />�MM r-. <br />,. • WINAr NEW+- -cam © �� <br />h <br />M <br />z <br />< <br />W. <br />�o <br />�m <br />M <br />0. <br />' <br />M <br />_ <br />N <br />to <br />5 <br />EHD:3.06 &01/10 <br />W. <br />q/ 13 �—b <br />" <br />WELL PUMP PERNIF <br />t,'d <br />VZ9£Z9960Z <br />DUB S]811!JQ eoueiAind d00:ZL Zl V� AON <br />