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zw <br />W / <br />2W <br />aaIX <br />6ti�6 "N AM:0( L[0Z '9l '}l0 IWI J P@Al;);y j <br />WELUPLIMP PERMIT / <br />SAM JoA0U1NCOUNTYENvwoNMENCALHEALTH DEPARTMENT 1868 EASTHAZELTONAVENUE-STOCKTONCA95205-(269)488-3420 ^ J <br />NVIII-KEFUNDABLL rLKM1T %,,ALL(LU7):f03-/b:7/ FUK INSET[: 11UNJ GCrIKCJI T LAK FKUM DATt tSSULD <br />JOB ADDRESS 15777 TES HArney Ln r c,,,jzYodi Ca 95240 <br />CRO53 STREET T u I I y R d APN 05 ) � � () PARCEL SIZE � V ' � I LAND US PLICATION d i <br />OWNERNAME Plants and Produce Jo/AL —406-3462 <br />OWNER ADDRESS 15 7 7 7 E Harney Ln CITYISTATEIZIP L o d i C a 9 5 2 4 0 <br />CONTRACTOR Purviance Drillers, Inc. pHoa09-887-3554 I, <br />CONTRACTOR ADDRESSP. 0. Box 6 4 CITYrsTATFJZIP L i n d e n, C A 95236 <br />SUBCONTRACTOR PHONE <br />scTOR ADDRESS <br />X: C-57 , I C-61 _ 13-09 _ <br />CITWS-rATVZIP <br />NUMBER 3 7 7 7 2 3 EXPIRATION DATE 7/ 31 / 19 <br />GEOGRAPHICAL Ir1FoRNUUTON: Coordinates X Y Township_ Range Section <br />NTE IOEo USE Domes:irJPrivate i Inigadtion/Agricultural :J Irdustrlal 0 Water Quality Monitoring , Soil Sampling/Character¢agon <br />Public Water System <br />It diftm.l .'rom Cl— er ys em — a — w - <br />TYPE OF WORK New Well Replacement Well WeIJ AlleratwrJModifiragon L Other <br />n Monitoring Well(s) 9ofwells rl Sail Bor"(S) xvreodvs i Geotechnical narlarngs <br />Out-OfSenrice Well Out-OfService Well Renewal Cross -Connection Repair <br />:. New Puma 4k Puma Reolacement Pumo Renair Raise Well Casino <br />Drilling Method Mud Rotary - Air Ralary J Auper . Cable Tool _ Push Point 1! Other <br />Proposed Well Depth ft Excavation in diameter Open Bottom Gravel Pads/Gravel Size in diameter <br />Canduclor Casing in diameter I Conductor Casing Depth ft <br />Well Casing Diameler_ in ThicknessiGauge/ASTM Sched ❑ Steel _ Plaslic '- Stainless Steel r_ Other <br />Grout Seal Depth ft = Neat Cement r941bbag/5-10gafwater) :Sand Cement _sack mxl7gad water <br />Bentonite (2046 sotdS) - Other <br />Grout Racernent Method L Pumped - Free Fall C Other Retardant I Accelerator (name) <br />PEDESTAL Installed By Driller -- Pump Contractor I= Other <br />Concrete Pedestal LDimensiorls:Widlh It Length ItThick in LChristy Box L, Stove Pipe <br />PUMP • Submersibleu Turbine -� Other HP Pump Set ft Stand ngWater Level ft <br />1 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, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTNE WITH THE CALIFORNIA CONTRACTORS STATE UCENSE HOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />Cn <br />0 <br />a <br />m <br />EPARTMENT USE ONLY G <br />Appfiratian Accepted By Date Area Employee Ilk w v <br />Grout Inspection By Dale ❑ SPECIAL Well Permit <br />Pump Inspection By u Date ❑ WAIVER Received <br />Soil Bering Inspection By Dale Constructed Well Depth ft <br />COMMENTS <br />PE <br />Codes <br />SC Received <br />Info 8 <br />Amount Date Perrn1V Invoice# Well ID# <br />Remitted Service Request # <br />3 1 <br />S <br />END 43 OS 'NEIL /PUMP PERW <br />4aa12 <br />V -d VZSCZ9260Z <br />M <br />0 <br />P�y <br />6 � 0 <br />out saejji.IQ eoueiA)nd est':OL LL 9L 100 <br />