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3 <br />T^;kxk SS00 "N AVW l l Ml '96'daS awil paAi;);� <br />WELLIPUMP PERMIT <br />SAP! JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1668 EAST HAZELTON AVENUE- STOCKTON CA 95205 - (209) 4683420 <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 9 YEAR FROM DATE ISSUED <br />�JOBADORESS 5001 E Eastview DR 0,T,.IZ,pStackton CA 95212 <br />CROSS STREET Freesia Ave APN t 1 113 I= 0 A5 ARCELSQE O t.�'' _ <br />LAND USE APPLICATION <br />IOWNERNAME Lodi Unified School District PHONE 209-810-3962 � <br />'CXvv&R AnOREss 13 0 5 E V i n e S t Crw/SrATe/ZiP L o d i CA 95240 <br />CONTRACTOR Purviance Drillers, Inc. PHONE 209-867-3554 <br />CONTRACTOR ADORES 5 p • 0. F3ox 64 CtTYISTATEIZIP Lindell, CAq5231 <br />(SUBCONTRACTOR PHONE <br />(SUBCONTRACTOR ADDRESS CITY/STATEJZIP <br />ucENSE G57 . C -61 <br />D-09 Other NumaER 3 7 7 9 2 3 E,,RATtON DATE 7/31/17 <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section <br />I VTENDED USE ❑OmesG:JPrivate i IrrigadonlAgrieullural C Industrial Water Quality Noretoring Z Soil Sampling/Characterization <br />Public Water Syslem <br />If djNmrtfa 0-1 or. er am ame a ar one N ­ <br />TYPE OF WORK _ NeWWell � Replacement Wel ': Well AlleratioNModificatiion :i Other <br />-: Monitoring WeE(s) # of wells ¢ : Soil HOnng(s) r.1 Wrings � Geotechnical N of borings <br />Out -Of -Service Weil Out-017Service Well Rerewal n Cross -Connection Repair <br />Drilling Method _ Mud Rotary _ Air Rotary ..Auger _ Cable Tool Push Point ; Other <br />Proposed Well Depth fl E)=avation in diameter - Open Bottom Gravel Pack/Cravel Size in diameter <br />L , Conductor Casing in diameter 1 Conductor Casing Depth ft <br />Well Casing Diameler_ in Ttickress/GaugeJASTMSrhed ;;Steel 7iPlastic Stainless Steel Other <br />Grout Seal Depth ft D Neat Cement (94/bba95-TOgaJ%vater) Sand Cement sackrW-ygalwater <br />Bentonite (20% scEds) : ! Other <br />Grout Placement Method C Pumped _ Free Fail - 011her <br />Retardant / Accelerator (name) <br />PEDESTAL Installed By _Driller ?ump Contractor Other <br />Concrete Pedestal.. Dimensions: Width R Length fl Thick in a Ghristyt3ot< Stove Pipe <br />PUMP • Subnersiblel_: Turbine :: Othar HP= Pump Set ft Standing Water Level ft <br />I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY ORCINANCESr STATE LAWS, AND RULES AND REGULATIONS. 1 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 />ANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209),A53-7697 <br />�-,,E Corporate SecretaKTyV,2Q-jw <br />,EIVEID <br />26 2016 <br />�AL HEALTH <br />pq Y <br />RF�F �o <br />NQ(r,� ?0�" <br />11= MENT USE ONLY <br />Application Accepted By Dale �i, (� l Area D Employee IDC <br />Grout IrLspectiDn By Date D SPECIAL Well Permit <br />Pump Inspection By Dale Z ' WAIVER Received <br />SGilboring Inspon By <br />COMMENTS (U J 1 t� <br />Date <br />it <br />PE <br />Codes <br />SC <br />Into <br />I Received <br />By <br />Check4f <br />Cash <br />Amount Date <br />Remitted <br />Permit! <br />Service Request A <br />Invoiced Well 109 <br />`1-�-7 <br />Sl:�9t�75�;iJw <br />W pDa37Y�s3 <br />I <br />EHDa3A6 W �LN o1� <br />arlDrt2 OCO <br />%vaL ?F'1JMP PERRII T <br />Z -d tZSCL2960Z out sJellua eoueiAand d91:90 ZO 9Z add <br />