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9tiL6'°N--AdLS:O—L106—'SI "I(]_aLui1 paniaaay <br />WELUPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1966 EAST HAZELTON AVENUE - STDCK11UN CA 95205 - 1209) 4684420 <br />NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JoaADDRESS 5103 E Ashley CITYIZIPStockton 95212 <br />,d �, a <br />CROSS STREET APN PARCEL S� �I.. 1 I LAND USE APPLICATION 9 <br />OWNER NAME Kevin Stanfield - +` pH 09-931-7724 <br />OWNER ADDRESS 5103 - E Ashley V111 CrTM/sTATErap S t o c k t o n C A 95212 <br />CONTRACTOR Purviance Drillers, Inc PHONE 2109-887-3554 <br />CONTRACTOR ADOREPC) $ o x 64— <br />crrwsrATI L i n d e n, CA 95236 <br />ADDRESS <br />CITY/STATVZW <br />PHONE <br />LICENSE X C-57 0 C-61 0 D-09 LI Other NU HBER FJIPIRAmON DATE <br />DomFsnc WELL SAMPLIING] C General Mineral/Coliform Bacteria (4391) C Dibromochtoropropane (4392) :i Arsenic (4393) <br />IwMNGFD 133E 91 Comestic/Privale D I"al"mnlAgricldtural ❑ Industrial ❑ 'Nater Quality Monitoring 7 Soil Sampling/Characterization <br />❑ Public Wal— System <br />INiterent from Own . mter System Name Gontacl Name or Phone Number <br />rr yr WORK Li New Well C Replacement Well❑Well Alteration/Modification O Other <br />— <br />0 Monitoring WMI(s) del of wells ❑ Soil Boring(s) i0 of conng it Geotechnical <br />D Out -Or -Service Well ❑ Out -Or -Service Well Re—I n --- ;- <br />A o1 bo rings <br />❑ New Pum d Pum Re lacxment L Pum R air 7 Raise Well Casir. <br />WELL CarlsTRucnoN <br />Drilling Method 3 Mud P.olary � Air Rotary I-' Auger Cl Cable Tool D Push Pcint ❑ Other <br />Proposed Weil Depth ft Excavation in diameter 0 Open Bottom 0 Gravel ParJJGravei S ze in diameter <br />❑ Conductor Casing in diameter I Conductor Casing Depth <br />Wets Casing Diameter_ in Thickness/Gauge/ASTM Schell D Steel O Plaslio ❑ StairI Sleet D Other <br />Grout Seal Depth (1 U Neat Cement (94 lb bag,5-10 gal Wa(er) D Sand Cement <br />sack nix/7 gal water <br />Bentonite (20% solids) C Other <br />Grout Placement Method ❑ Pumped D Free Fall [I Other D Retardant I Accelerator (name) <br />PF <br />uury w Iud6jcv U Ulher -- <br />❑ ConcretePedestalr;Dimensions-Width ft Length nThick in .3 Christy Box ❑Slovepipe <br />PUMP 10 Submersble❑ Turbine D Other <br />HPPump Set ft Standing Water Level tt <br />I HEREBY CE RTll^/ THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL 13E DONE IN ACCORDANCE WITH SAN <br />JOAQUtN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. ( ALSO CERTIFY THAT MY REQUIRED LICIS <br />ENSE <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIAN <br />WORKERSSZ PENSATION LAWS CE WITH ALL <br />DIE -C <br />ENVIRONra9i <br />PERMIT <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Sal Boring Inspection By <br />COMMENTS <br />CE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />T, Corporate SecretaryA, /-2/- i7 <br />Date��(I <br />Date <br />Date <br />Z <br />Date <br />API I I Employee ID# <br />C SPECIAL Wel) Peffnit <br />L W.avER Received <br />Constructed Well Depth <br />EHD43-06 dMIJ'0 <br />9'd bL9EL8860Z <br />WELL/ Ump PERMIT <br />CUA SkajjikQ aoueinknd <br />a <br />a <br />loo <br />p <br />0 <br />4v <br />6r <br />4,. <br />� sl <br />C" 'S <br />v X1%5 <br />Q z <br />d8t:t0 L � 9 � Cao <br />