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Cm <br />LU <br />Uj <br />0 <br />LU <br />*� WELUPUMP PERMIT V v <br />SAM JOAQUIN COUNTY EwIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZFSTON AvmuE-SToCKTON CA 9520S - 120914SB-3420 <br />r <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FORINSPECTIOnS EXPIRES 1 YEAR FROM DATE ISSUED <br />JoeADOREss 8858 N .JackTone Rd cl„rmPStockton 95212 <br />CROSS STREET F ; g -h r APN PARCELSrZE Ar L.arlo USE APPUCATwNTI <br />oWNERNAIAE Gaylan Queirolo p,,Q)9-483-8509 <br />OwNERAooREu"3322-Willowbrock Cr CrTYISTATE21PStockton CA 95219 <br />CONTRACTOR Purviance Drillers, Inc PHONE 209-887-3534 <br />9 5 2 3 6 <br />CONTPACTOR ADDRESS PO Box 64 CfrYfSTATPMZlPLinden, CA <br />Si1000NTRAGTOR PHONE <br />SU9CONTRA CTOR ADO RESS CMISTATEM <br />L1cENsE X C-57 U C-61 0 Dag C Other NUMI]FR % DIDiRATON DATE ) - <br />n....��,,.-rnr�, , c,,.ro� �.r;• n r:emeral MinPrnlIrnliform BacteSa (43911 t. Dibrornochlompropane (4392) : Arsenic (4393) <br />NTENoEoUsE 0 DomesticlPrivate p InigauaNAgricuRural C Industrial 0 WaterOuality Moniloring 0 Sal SamplinglCharacterim6on <br />❑ Public Water System <br />ircimeremrmm Omer. Mier System Name Coated Nane or Plaxre Nnmbcr <br />TYPE OF WORK D New Well G Replacement Well c. vvNi PAeracroree 00MCEMon a vu - <br />0 Morulering Well(s) # of wells 0 Sal Bortng(s) o ar b rINS ❑ Geotechnical got borings <br />D Out-Or-Servicel'Vell 0 Out rvi <br />Of-Sece Well Renewal 0 Cross -Connection Repair - <br />n N— P'- IN Thane Reola,=nent C. Pump R%a(r D Raise Well Casing <br />Drilling Method 0 Mud Rotary C Air Rotary 0 Auger D Cable Tcol 0 Push Point C Other <br />Proposed Well Depth ft Excavation in diameter Open Bottom O Gravel PaWGravel Stze in diameter <br />D Condudor Casing in diameter I Conductor Casing Depth tt <br />Well Casing Diameter_, in ThicknesslGauge/ASTM Sched D Steel 0 Plastic D Stainless Steel 0 Other <br />GroutSeal Depth_ft 0 Neat Cement (94 lb bay5-10 gal water) D Sand Cement sack nax;7 gal water <br />Cl Bentonite (2C% sodds) 0 Other <br />Grout P lacement Method G Pumped D Free Fad 0 Other G Retardant I Accelerator (name) <br />PEOE9TAL Installed By D Driller 6 Pump Conhador D Other <br />D Concrete Pedestal uDimunsions: VMth it Length ft Thick In O Christy Box .I stove Pipa <br />PUMP Submersible Turbine 0 Other HP 5� Pump Set it Standing Water Levely Fl <br />I HEREBY CERTIFY THAT 1 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. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE NTH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENATION LAWS- <br />INIM 12MVANCE4 NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />T"Sorporate Secretar&T, al>eLjP' <br />$lGNEO <br />Z w nni�,r o <br />LI J <br />AreaEmployee IDAt j��/v/ <br />❑ SPECIAL Well Permit 1111 <br />❑ WAIVER Received <br />Constructed Well Depth fl <br />Vd <br />EHD434,'b 81a1119 <br />VZ9U2260Z <br />out S)ajji-IQ aoueiA)nd esti: � 6 8� OZ qac <br />�r�.LH/ry����I�■��� <br />f/f'IN V' 01 -MI <br />Vd <br />EHD434,'b 81a1119 <br />VZ9U2260Z <br />out S)ajji-IQ aoueiA)nd esti: � 6 8� OZ qac <br />