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0 <br />W <br />L606 "N AdSI:E L106 'Sl'2nV awil paAI;0;� <br />WEI I (PUMP PERMIT <br />SAN JOAOUIN COUNW ENVIRONVnUiTAL HEALTH DEPARMENT 1868 EAerr HAZE1TON AVENUE - STOCK'MR CA 95205 - (209)468342o <br />NON-REFUNDABLE PERMIT CALL 209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FRom DATE iSSUEl7 <br />JosAwms2066 Paterson CI,Y� ,S�ANOwa <br />t�ockton CA 95215 <br />CROSS STREET_ HW}r 26 APN � ," O PARCELSMEZ.7 ILUseAPcAnoN4 <br />OWNER NAME Guadalupe Carrasco —f p„,cwL209-923-4422 , <br />owNERADDREss1290 Camilla Ct Cnv/STa�,,,Manteca CA 95337 <br />CONTRACTOR Purviance Drillers, Inc. PHORt 209-8877—t 3554 <br />CONTRACTORAODRES.9 P- O- SOX 64 CrWSTATSIMP Linden, C`f 95231 <br />ADDRESS <br />L icENsE All C-57 _ 4.-61 i: D -OR _ Olher <br />CirnSTATVZIP <br />NumsER 377923 r=xmAnON DAT/31/1qE r -7 <br />GEOGRAPHICAL INFORATAMON: Coordinall X Y Township_ Range Section <br />INTENDED USE T DomeslituPdvate a Imgallon/Agricultural L Indusl6al _3 Water Quality Monitoring = Soil SamplinglChamcter 8licin <br />Public Water System <br />Itdlltcrenl Um Owner, er ys em me arms or .orx, mxr <br />TYPE OF WORK Nf ., VVelI _ Replacement Well, -:.: WL41 AlterationlModificaton Other <br />tbtiloringlNell(s�� :of wells Soil Borings) :orborinas r Geotechnical ea100E"9s <br />Out-O&Service Well F Out -Of -Service Well Renewal :-I Crass -Connection Repair <br />Drilling Method a Mud Rotary Air Rotary . Auger Cable Tool _ Push Point Other <br />Proposed Well Depth ft Excavation in diameter Open Bottom _Gravel Pack/Gravel Size in dituneler <br />_ C0nduclorCasing in diameter 1 Conductor Casing Depth R <br />Well Casing Diameter _ in Thickrte s/GaugeJASTM Srhed Steel _ Plastic = Stanless Stee) _Other <br />Grout Seal D Ih <br />ep R = Neat Cement (94lbbagB•109a)weterj _ Sand Cement sackrnixflgalvrata <br />Bentonite (20% solids) ! Other <br />Grout Placement Method 7. Pumped '; Free Fall -Other RetardantIAccelerator (name) <br />PEDESTAL Installed By --Driller 51, Pump Contractor Olher <br />':ConcretePBdestal:_Oimension5:Wrdlh H Length _ RThlck ,n _ChrislyBox s_,SiovePFpe <br />._Putty 4SubmersiblecTurbine .Olher HP Pump Sel ft StandingWalerLevei ft <br />1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT T14E WORK WILL BE DONE IN ACCORDANCE WrrH SAN <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGUUTIpNS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />WORPENSAT1pN <br />CURRENT AND ACTIVE WITH THE CALIFORNIACONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE VATIH ALL <br />LA <br />MIN M 24 CE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SICNED_E�t T,nE Corporate Secret�rr �-/S-/7 <br />y <br />D <br />c <br />a <br />m <br />wFNr <br />rl V�Q <br />Z•d <br />41�EfL�RTMENT LYSE PNLY <br />Apploralion Accepted By Data ' Ata Employee II9J� <br />Grout inspection By Date Ll�Well Permit <br />Pump Inspection By r Df._0I INA] Received <br />Soil Boring Inspection By Date Constructed Weil Depth ft <br />COMMENTS <br />EHD C7 -e6 <br />4ON12 <br />tL5£L8860Z <br />Date <br />Invoice # Well lD# <br />� <br />