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601 °N M6Z :6 �06 '�6 'qac IWI J paA I;D;� <br />3 <br />WELLIPUMP PERMIT <br />SAN JOAQUIN COUNTY &VIRONMEnTAt HEALTK DEPARTMENT 1868 EASTHAZELT@I AMMUE-STccKTON CA 95205 - (209)488-3420 <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR mom DATE IssuED <br />JOBADDR:33 1141 N Beecher Rd cnrI,,&tockCon CA 95215 <br />I <br />CRossS ,e.130 tN� APN - 0—! o PARCELS1l11_,'q_jlJ1 USE APILICATI-10 <br />�orrsvER NASEJ o Fin tl.r m � L2 _ _ -- aHar2 0 9 —9 31— 3 4 7 1 <br />O'WVNER ADDRESS 1271 N -Beecher Cm.ISTA Stockton CA 95215 <br />CONTRACTOR Purviance Drillers, Inc PHONE 209-887-3554 <br />CONTRACTOR AnOREss PO B o x 64 CITYiSTATE0PL i n d e n, CA 95236 <br />UBCONITtACTOR <br />UHCONT"i;TaR ADDRESS <br />CFTYISTATEZP <br />C57 6 C161 D 0-09 U Other %WMI 1 _ <br />PHONE <br />E)94RATIDN <br />Dow: -nc WELL SA.v PLrno: P General MinerallCobfDrm Bacteria (4391)-, Dibromochloropropana (4392)'] Arsenic (4393) <br />IrrrENnep Use G DomestJUPrivale • Irrigation/Agroutural C Industrial C Water Duality Manito ing O Scll SamplingfChwacleriraUon <br />❑ Public Water System <br />rd0lerent rram Owner. VaeW System Nam Corded Nemo cr Pt»n Nnmaer <br />TYPE OF WORK (2 New Wets L Replacement Well C WetlAlterationfModrticatian D Other <br />O Moniloting WeA(s) # of YfeiCs C Soil Boringls) oor oanaes n GeotecWical a OS DOn`us <br />D Out -Or -Service Well C Out-OfSenace Well Renewal D Cross -Connection Repair <br />Drilling Method ❑ Mud Rotary C Air Rotary ❑ Auger O Cable fool ❑ Push Point D Other <br />Proposed Welt Depot it Excavation in diameter i Open Bottom G Gravel PackrGravel Size in diameter <br />D Conductor Casing ct diameter f Conductor Casing Depth ft <br />Well Casing Diameter_ in ThIcknessfGaugelASTM Schell 7 Steel 0 Plastic 0 Stainless Steel n Other <br />Grout Seal Depth_ft D Neal Cement (94 Ib bag6S10 gal water) D Sand Cenvent sack albU7 gal water <br />U Bentonite (20% solids) ❑ Other <br />Grout Placement Method C Pumped D Free Fall 7 Other G RetmdwtJAccelerator (nam a) <br />PEDESTAL Installed By U Driller D Pump CWtradcr ❑ Other <br />R Concrete Pedestal ❑DimenaaanrVuidth fl Length RThick in D ChristyElox :I Stowe Pipe <br />IRV-- ❑ Submersiole*Turbine D OtherHP Pump Set R Standing Water Levef7 <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. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BDARD AND THAT I AM IN COMPLIANCE VnTH ALL <br />WORKERS COMPENSATION LAWS. <br />UM 24 HO ANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 95 769 <br />sraFoporporate Secretar&,_ o2�� <br />Lj <br />Area E-playee 11111 <br />H <br />AAA <br />R:JL._8u <br />G <br />ones,, <br />®� <br />cmc <br />n <br />0 WAIVER Received <br />LL <br />Date <br />Cons"cted Well Depth <br />ft <br />Il, <br />Of CL <br />z <br />�J <br />Application Accepted By <br />Grout tnspection By <br />Pump Inspection By <br />Sal Bonny Inspection By <br />COMMENTS <br />N <br />a <br />A <br />PA V <br />MRO UIN coU <br />Ty OE�M� '4t <br />D,E ARTMENT U E <br />Date LY <br />Area E-playee 11111 <br />Oale <br />❑ SPECIAL Well Permit <br />Date 'j 10thy <br />0 WAIVER Received <br />Date <br />Cons"cted Well Depth <br />ft <br />1VE1L r�UVF PERLVT <br />t d VZSCZ9960Z OUB aoU1=iA_Ind dCo:�0 9l CZ 9e� <br />