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L M " N AdSti:� 8l0Z 9 a'aA quail paAia�ad <br />VVELLJPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARThfEIJT 1868 EAST HAZrLTON AVENUE- STOCKTON CA 852US - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL 209 953-7697 FDR INSPECTIONS EXPIRES 4 YEAR FROM DATE ISSUED <br />JOB ADDRESS - y g'BfA 11 l',{'I U 12d CITYJaP S t o ct o n <br />hREET__0'Pivt� APN 3 4O 4 O PARCEL SIS LAND USE APP <br />ucaTtoN 4INAb1E Denning, LLC 209-351-12 <br />PHONE 20 <br />ADORM 18600 Tobacco Rd!� aTYISTAT�z,PLinden, CA 95236 <br />4CTOR Purviance Drillers, Inc PHONE 209-8.87-3554 <br />iCTOR ADDRESS PO Box 64 CrrvfSTATFI7JPL i n d e n, CA 95236 <br />PHONE <br />ADDRESS <br />C-57 ❑ C-61 ❑ D-09 ❑ Other <br />DOMESTIC WELLSAMPUNc:O GeneraWneral/Coliform Bacteria (4391) - Dibromochforopropane (4392) -_ Arsenic (4393) <br />INTENDED USE D Domes FCMF vete Irrigation eCUhural ❑ Industrial D Water Quality Monitorino n Sail iAm Ninn/r'har , <br />❑ Public Water Syste <br />If dlRerenl from Owner. <br />Nairn <br />None ar <br />TYPE Or WORE WWORK ❑ New WeIJ C Replacement Well ❑ Well AlteretioNAfodificetion ❑ Other <br />❑ Monitoring Well(s) # of v/ells G Soil Boring(s) ° a borings ❑ Geolecitnical o or bon <br />dig U <br />O Out -Of -Service Well ❑ Out-Ot-Service Well Renewal D Cross-Conneaebn Repair �;A <br />_ ❑New PUMP XPump Replacemert ❑ Prenp Repair ❑Rake Well Casing N SDA <br />lu, g c... OI LIA, _ <br />Drilling Method D Mud Rotary C A7 Rotary 11 Auger 2 Cable Tool n Push Pant 11 Other wLTH D e. - <br />Proposed Well Depth fl Excavation in diameter 7 Open Bottom ❑ Gravel ParkJGravel Size in diameter <br />M Conductor Casing in diameter / Conductor Casing Depth fl <br />Well Casing Diameter -in Thirkness/GaugeJASTM Sched ❑ Steel ❑ Plastic D Stainless Sted J Other <br />Grout Seal Depth ft J Neat Cement (941b bagl5- 1`0 gal wale/) D Sand Cement sack mfx17 gal waler <br />❑ Bentonite(20%solids) ❑ Olher <br />Grout Placement Method ❑ Pumped ❑ Free Fall :] Other C Retardant f Accelerator (narrw) <br />PEDESTAL Installed By D DriOrr ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal ❑Dtrnenttions Width ft Length it Thick in FI Christy Box O Strive Pipe <br />PUMP ❑ Submersble Turbine ❑ Other HP Pump Sel 'f-� ff Standing Waler Level 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. ANO RULES AND REGULATIONS. I ALSO CERTIFY: THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORK PENSATIDN <br />MINI M 24 ANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALLA2091973-797 <br />SIGNED Tl�orporate Secretary 6 18 <br />Application Accepted By <br />Groullnspection By <br />Pump Inspection By <br />Sol Boring Inspection By <br />COMMENTS <br />M <br />EP RTMENT U E O LY <br />r <br />Date <br />Date�� <br />Date <br />Date ��TT <br />s��•WRVA ILYA ria <br />Aree� F1Ttployee Irw'IAJ( t7/ <br />❑ SPECIAL WAIT Permit <br />❑ WAIVER Received <br />Constructed well Depth it <br />to <br />v <br />0 <br />A <br />N <br />2018 <br />AAL H�rH <br />' 7G3 `133 <br />wELLRuv❑ PERMIT <br />bL98L8860Z out saejji_IQ aouq/und dL8:t0 26 90 aEW <br />