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i. <br />A <br />.7•d <br />H H 'ON Wd80:8 t[oZ '8l'2ny anvil paAianad <br />WELLIPUMP PERMIT <br />SAN JOAQWN COUNTYENVIRONMENTAL HEALTH DEPARimNT 11368 EAST HAZELTONAVENU£- STOCKTON CA 96205 - (209) 4684420 <br />NON-REFUNDABLE PERMIT CALL 209 963-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE IsSUm <br />5637 Solari Ranch Rd <br />Joe ADDRESS CIT,dZIS t o c k t o n CA 95215 <br />ICROss STREETE F o p p i e n o Rd API PARCELSIZE�2 LAND USE APPLICATION # <br />OWNER NAME Tamara Fooy pHq,209-993-8071 <br />OWNERADDRPBS 5637 Solari Ranch Rd cn-,rs7A,FjzIPS_tockton Ca 95215 <br />(CONTRACTOR Purviance Drillers, Inc. PH.209-887 _3554 <br />CONTRACTOR ADDRESS P - 0. B o x 6 4 CITytBTATwap Linden, CA 95236 <br />ADDRESS <br />X_ C-57 --I C-61 D-09 Other <br />CITY/STATE/ZIP <br />NumeER 3 7 7 9 2 3 <br />EXPIRATION <br />GEOGRAPHICAL INFORMAMON: Coordinates X Y Township_ Range Section <br />INTENOeD USE YDornesliwPrivate 1:' Irrigation/Agricultural Industrial D Waler Quality Monitoring [I Soil SamplingfCharacterization <br />Public Water aystem <br />Ifdinerenlfmm Owner cr m amo COP s ameor one um r <br />TYPE OP WORK I New Well .- Replacement Well j Well Alteral,onlModi6catlon Other <br />rIMonitoringWell(s) Sofwells f! SallBoring(s1 °o1Dort-9s Geotechnical acrrronr�;s <br />I : Out -Of -Service Well n Out -Of -Service Well Renewal -- Gros -Connection Repair <br />Drilling Method a Mud Ro(ary :. Air Rotary -. Auger Cable Tool J Push Point !.; Other <br />Proposed Well Depth It Excavatian in diameter D Open Bottom C Gravel PaddGravel Size in diameter <br />Cortduclor Casing In diameter / Conductor Casing Cepth R <br />Wei Casing Diameter! in 7Uckness1GaugafASTM Sched (i Steel i Plastic F Stainless Steel r_; Other <br />Grout Seal Depth It L Neal Cement (94 /!1 hag45-10 gal watei) - Sand Cement sack rrlixt7 gal water <br />-1 Bentonite (20% solids) n Other <br />Grout Placement Method U Pumped D Free Fall C Other ❑ Retardant IAccelerator (name) <br />PEDESTAL Installed By i I Driller C Pump Conlractor u Other <br />i <br />I.r Concrete Pedestal LDimensioers: Width R Length ft Thick in I; Christy Box u Stove Pipe <br />I <br />PUMP Submersiblel I Turbine LI Other HP Pump S II Standing Waler Level it <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 j <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATIO <br />MIN 1111124,1 A ANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209) 9633-7697 <br />S, Ai/ 2- TITLE C o r p Secretary DATE //7 <br />E <br />Application Accepted By, <br />(rout Ispectian By <br />Pump Inspection By <br />Soil Baring Inspection By <br />COMMENTS <br />ARTMENT E N Y <br />Date <br />Date <br />Date <br />Cate <br />Area <br />6 _ - Fmployetk <br />eIDiC�[G� <br />El SPECIAL Well Penn it <br />❑ WAIVER Received <br />Constructed Well Depth ft <br />18 201? <br />ECOID <br />PE Sc Received Check#f <br />Codes Info B Cash <br />Amount Permit/ <br />Dat <br />Remitted Service Re uest# Invoice# Well IDN <br />211 r <br />DI&A <br />bp <br />EHD 43AM <br />4/9(.'12 <br />bL5EL9860Z <br />WELL 1PUNP PERMIT <br />out sielp4 eoueimnd dt0:£0 L � 9Z 6ny <br />