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REC�t� <br />SEp � 1 <br />d01►Q�1 <br />f, ROS <br />of <br />9SN'ON AVLS:II LM '8 'd;S ;W1 j P;AI;3;� � <br />WELLIPUMP PERMIT P <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1888 EA5THA2HLTON AvENuE- STMKTON CA 95205 - (209) 468.3426 <br />NON-REFUNDABLE PERMIT CALL (208) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISWUEL <br />JOB ADDRESS 10749 N 7 `% <br />J�ackTone/ � <br />Rd 1PLodi 95240 <br />CROSS STREET Live 0 a k fl d AIN I �- 10 2.7- PARCELSIYe U LAKE USE APPLICATION # <br />OWNER NAMFBritta.lia Ventures LKhal 511; <br />LLC ) PHDNE209-9414500 <br />OWNER ADDRESS P.O. box 170 cnrwsTAwjzP L i n d e n 95236 <br />CONTRACTOR Purviance Drillers, Inc. "09-887--3554 <br />CONTRACTOR ADDRESS P - 0 - B o x 6 4 CITY/STATFIzIP Linden, CA 95236 <br />SUBCONTRACTOR ADDRESS <br />LICENSE XJ C-57 'I C-61 I D-09 L' Other <br />CITY/STAWJZP <br />Numam 3 7 7 9 2 3 ExpiRAnoN <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br />INTENDED USE DomestirlPrivate XII-rigation/Agricultural III Industrial 0 WaterOualiry Monitoring a Soil Samping/Characterization <br />_ Pudic Wafer Sys elms <br />Ifdinrd <br />eY fmm Oacer. w em ame °n r+ne °� ron w <br />TYPE OF WORK -: New Well Replacement Well L. Well AlteratioNModi9calion 1 Dow <br />r- Monitoring Well($) *of wets I'. Soil Boring(s) rto1 eon - Gedechniral tt °t bor4gs <br />r: Out-ORService Well n Oul-Or-Service Well Renewral _ Cross -Connection Repair <br />0 New Pumo YPLMD Replacement ; I Pum. Renair - Rni.n wen <br />Drilling Method 'd Mud Rotary : Air Rotary _ Auger I Cable Tool J Push Point I; Other <br />Proposed Well Depth ft Excavation in diameter U Open Bottom - Gravel Pack/Gravel Size In diameter <br />-: Conductor Casing In diameter / Conductor Casing Depth ft <br />Well Casing Diameter_ in ThcknesslGauge/ASTM Schell I'I Steel I: Plash - Stainiess Steel ii Other <br />Grout Seat Depth ft '_ Neat Cement (94 /b bag/S io gal werer) n Sand Cement sack mdxr7 gal water <br />- Bentonite (20% solids) 7 Other <br />Grout Placement Method t: Purnped -. Free Fall U Other Relardent ! Accelerator (name) <br />PEDESTAL Installed By : Driller - Pump Contractor D Other <br />Concrete Pedestal _ Dimensions: IMdlh It Length N Thick in Christy Box ! Smve Pipe <br />PUMP Submersible_. Turbine J Olttet HP Pump Set ft Standing WaterLevel It <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE YYORK WILL BE DONE IN ACCORDANCE WrTH SAN <br />JOAOUIN COUNTY ORDINANCES. STATE LAWS. AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE 1S <br />CURRENT AND AC WITH _THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN CCMPUANCF- WITH ALL <br />M1M:24 R4DVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209),453-7697 <br />TITLE C o r p Secretary DATE -,q—! 7 <br />U5 <br />M <br />T7 <br />C=3 <br />CIO <br />EPARTMENT USE ONLY f / <br />AppllcatPon Accepted By _ QC Date - Area y 141 Employee ID. t+ S 1-G T i - C% <br />Grout Inspection By Date ❑ SPECIAL Well Perrnit <br />Pump Inspection By d Dale O WAIVER Received <br />Soil Boring Inspection By Date Constructed Wall Depth ft <br />COMMENTS <br />PE <br />Codes <br />Sc Received <br />Into B <br />Check## <br />Cash <br />Amount <br />Remitted <br />PenniV <br />Servleo RequeatV Involce-# Well ION <br />y3u► <br />4sv <br />�.7 <br />�l <br />u�P 7 - <br />CMC 43 -GO <br />1430112 <br />K. <br />bL9CL9960Z <br />W0. /PlrnP PERMIT <br />M <br />0 <br />M <br />out sielp(i eoueimnd et9: 6 6 L 6 80 dE)S <br />