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OZIc '°N 006:l l WI '96'qaj MIM paAl;�;� <br />I <br />WELL/PUMP PERMIT <br />SAN JOAQUIN Comm ENVLRONMENTAL HEAL.TR DE PARTtkNT 186S EASTHA2zLTON AVENUE -STOCKTON CA 95205 - (209) 4138-3420 <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FRDM DATE ISSUED <br />WTENDE D WE O Dornes;UdPrivate 0 Inic2ti0t0Agriw1Ural C IndUStrial Wate-Quality Monitadng O Soil SampEngfCharaclsizat;en <br />U P blt'AVNerSystern <br />1! G;Cemrr rmm C, m- WaterSys!em Nene Ccrlutl Nemo or Pnone N=br , <br />TYPE OF W ORK a New Well E Replacement wet G Well AlteratloWMadificab'on L' Other <br />a Mortltonngvv0(S) 0 o welts ❑ Sal Boring(s) safoodngs n GeotecPrniml awb.otrgs <br />O Out-0f-ServiceWal E Out -O --Service Well Renewal 7 Cross -Connection Ropair T' <br />Ll Nerr Pump III Pump Replacement G PLnp Repair D Ratse Well Casing <br />WELL CONSTAUCTICN <br />Drilling Method O Mud Rotary C Air Rotary 0 Auger P Cable Tool ❑ Push Point O 011ier <br />Proposed Well Deplh ft Excavation in diameter :, Open Botlom D Gravel PacklGravel Size in dameler, <br />U CanductorCasing in diameter 7 ConductorCasilgoeplh ft <br />Well Casing Diameter_ in ThicknesslGaugeJASTU Srhed O Stee! ❑ Rastc G SteINess Steel G OBter <br />Grout Seal Depth R R Neat Cement (94 1b 10 gar waL- J O Sand Cement saak morl7 gal rmler <br />U Bentonite (20% solids) U 01her <br />Grout Placement Method G Plnrtped 0 Free Fall 0 Other G Retardant IAcederator(name) <br />PEOESTAL Installed By O Driller a PUmpContracter D Other <br />9 Concrete Pedestal C1D11menslons: Width ft Length ft Thidc In l Christy Box n Stove Plpo <br />MEWL, _ Il SubmersihleRTurtnne 0 Other HP Pump Set R StandngWwerl-evel IZVO -ft <br />I HERESY 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 ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLJANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />24 <br />Application Accepted By <br />Grout l nspection By <br />Pump 1 nsper5on By <br />Sol Boring hvspectbon By <br />COMMENTS <br />NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />TmCorporate Secretar&,E <br />P <br />ti <br />n <br />X <br />sn <br />367 <br />PA <br />C����� <br />�IIj16 2018 <br />JOA <br />V/f&SN COMCIV.U <br />'rAfeAl 7, <br />TMGNT U E O Lv <br />Date %4f <br />Jae AOORE99 2 0 6 01 F, (i e t t l e m a n L, cnYrz,P L o rl i_ C a 9 r 2 4 0_ <br />. <br />Date <br />CRMSSTREP--r ( P illP n I K d APN iD PARCELS V 1:2�m VWCA&AITONA <br />Date l } <br />Ow,ERNAr,AEBoething Treeland Farms TRIC'%/Il� � CWMltotae09-727-3741 <br />•— <br />Date <br />I.T CITYISTATElL7Wr 00 d l a n ri .1111 IS CA 9 <br />OwjER ACoREss 2 3 4 7 Long V a l l e y R d <br />CDNrRACTOR Purviance Drillers, Inc PRONE 209—SR7-3554 <br />CONTRACTOR ACDRESS PO Box 64 CrTYJSTATFJZPL i n d e n, CA 95236 <br />ISUSCOTITAACTOR <br />PRONE <br />I <br />SUBCONTRACTOR ADDRESS CMfSTATEJZIP <br />UCENSE X C-57 U "1 i_` 0.09 U Outer NUNBtR E IPMATIOk DATE <br />DCteEsTic WE, 1 SAtApLtNo: ❑ General'AinerallColifonn Bacteeria (4391) F. Di4rorrochloropropane (4392) Am-enic (4393) <br />WTENDE D WE O Dornes;UdPrivate 0 Inic2ti0t0Agriw1Ural C IndUStrial Wate-Quality Monitadng O Soil SampEngfCharaclsizat;en <br />U P blt'AVNerSystern <br />1! G;Cemrr rmm C, m- WaterSys!em Nene Ccrlutl Nemo or Pnone N=br , <br />TYPE OF W ORK a New Well E Replacement wet G Well AlteratloWMadificab'on L' Other <br />a Mortltonngvv0(S) 0 o welts ❑ Sal Boring(s) safoodngs n GeotecPrniml awb.otrgs <br />O Out-0f-ServiceWal E Out -O --Service Well Renewal 7 Cross -Connection Ropair T' <br />Ll Nerr Pump III Pump Replacement G PLnp Repair D Ratse Well Casing <br />WELL CONSTAUCTICN <br />Drilling Method O Mud Rotary C Air Rotary 0 Auger P Cable Tool ❑ Push Point O 011ier <br />Proposed Well Deplh ft Excavation in diameter :, Open Botlom D Gravel PacklGravel Size in dameler, <br />U CanductorCasing in diameter 7 ConductorCasilgoeplh ft <br />Well Casing Diameter_ in ThicknesslGaugeJASTU Srhed O Stee! ❑ Rastc G SteINess Steel G OBter <br />Grout Seal Depth R R Neat Cement (94 1b 10 gar waL- J O Sand Cement saak morl7 gal rmler <br />U Bentonite (20% solids) U 01her <br />Grout Placement Method G Plnrtped 0 Free Fall 0 Other G Retardant IAcederator(name) <br />PEOESTAL Installed By O Driller a PUmpContracter D Other <br />9 Concrete Pedestal C1D11menslons: Width ft Length ft Thidc In l Christy Box n Stove Plpo <br />MEWL, _ Il SubmersihleRTurtnne 0 Other HP Pump Set R StandngWwerl-evel IZVO -ft <br />I HERESY 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 ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLJANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />24 <br />Application Accepted By <br />Grout l nspection By <br />Pump 1 nsper5on By <br />Sol Boring hvspectbon By <br />COMMENTS <br />NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />TmCorporate Secretar&,E <br />P <br />ti <br />n <br />X <br />sn <br />367 <br />PA <br />C����� <br />�IIj16 2018 <br />JOA <br />V/f&SN COMCIV.U <br />'rAfeAl 7, <br />TMGNT U E O Lv <br />Date %4f <br />6 �� V <br />— Employee ID#// <br />Area'SPECIAL-Well <br />. <br />Date <br />0 SPECIAL Well Permit <br />Date l } <br />O WAIVER Recelved <br />Date <br />Constructed Well Depth R <br />DMIZ—U4 WV18 <br />'NBL/PUW- PI R M rT <br />L'd VZSU2960Z oul s.lalli.iQ eoueiAand <br />doL:ZL 9L 9Zq%N <br />