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le <br />L9N AdSti 2 l 0 Z '9 'A PW awil paAia a� <br />WELLIPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH D EPARTNENT 1868 EAST HAZELTON AVENUE- STOCKTON CA 95205 - (209) 468.3420 <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />Joe ADDRESS 14513 E Sargent RD <br />CROSS STREET—Fa//11 APS n <br />O'wNER NAME O n k a r J u d g e <br />t RD <br />OWNER ADDRESS 14513 E Sargen <br />CONTRACTOR Purviance Drillers <br />CONTRACTOR ADDRESS PO Box 64 <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE X C-57 D C-61 7 D-09 0 Other <br />( 9 CITY1Z)P Lodi o <br />/ V PARCEL SIZED U3E APP CA710N # <br />PHONE <br />cmnsTATE�z,P L o j i, C A <br />Inc PHONE 209-887-3554 <br />CRYISTATEILPLinden, CA 95236 <br />PHONE <br />CnTYJSTATEIZIP <br />NUMBER 3 7 7 Q 2 3 ExPIRATIOH DA., 7/31/19 <br />m <br />g <br />s <br />v <br />DOMESTIC WELL SAMPUNW ❑ General Mineral/Collform Bacteria (4391) C Dibromochraropropane (4392) -,Arsenic (4393) <br />INTENOEo USE C DomestidPrivate AlmoationlAgricultwal C Industrial G Water Quality Monitoring . Soil SamplinglCharacterization <br />Public Water System <br />Ir c1demra from owner. Water System Name Canletl e Namor Phow Number <br />TYPE OFWoRIc O New Well G Replacement Well O Well AAeration/Modification 0 Other <br />>7 Monitoring Wells) # of vmtts CI Soil Boring(s) ° or non vs n W 15.ru d <br />fn <br />d7 Cut -Of -Service Well G Out -Or -Service Well Renewal 0 Cross -Connection Repair <br />S <br />0 New Pump kfumpReplacement 0 Pump Re airTI❑Raise Well Casln ♦ /,� <br />WELLCONSTRUCoN <br />v <br />} , <br />Drilling Method n Mud Rotary n Air Rotary 7 Auger C Cable Tool 0 Push Point C Other I <br />' <br />dnmeter <br />Proposed Well Depth ft Excavation In dlameter C Open Bottom n Gravel PacidGravel Size--- -"IV. <br />R <br />O�V <br />✓ <br />❑ Conductor Casing in diameter , Conductor Casing Depth f( Dia <br />Well Casing Diameter _ in Thidmess/GaugeIASTM Schell ❑Steel 0 Plaslic C Stainless less Steel C Other ENV Qlj) <br />C <br />Grout Seal Depth fl 0 Neat Cement (9416 oov <br />ag'S-r0ga1 wafer) 0 Sand Cement sack/jetwa <br />7) <br />C Bentonile(20%solids) 0 Other `-,z <br />q <br />"t <br />7 <br />MFNT <br />Grout PlacementNlelhod C Pumped 0 Free Fall C Other 71 Retardant/Accelerator(name) <br />PEDESTAL Installed By 0 Driller 0 Pump Contractor 0 Other <br />n Concrete Pedestal ODimenato w yYdth ft Length ft Tluck in C Christy Boz7 Stove Plpa <br />Pure ubmersible0 Turbine D Other HP f570 Pump Sel - ft Standing Water Level ft <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WLTH 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 1 AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LA <br />MINI 24 H�ANCE CEREQUIRED FOR INSPECTIONS- PLEASE CALL (209 9 3-7697 I <br />Secreta <br />slcN�\ T4arporate -10.1'.6/1R <br />application Accepted By <br />Grout Inspection By <br />Pump Inspecdcn By <br />Soil Boring Inspedicn By <br />COMMENTS <br />ECEIVE <br />MAR 0 6 1013 <br />PERM.ITISERV r. � <br />PA TMENT UE ONhY <br />Date71h 1AF Area <br />Employee y <br />Date D�Well Permit <br />Date LI WAIVER Received <br />Date Constructed Well Depth ft <br />EHO43-00 9101116 <br />Uk;� 76 3'tD3 �3 <br />WELL,PUNP PER ALIT <br />E'd tLSCZ9960Z out sa9jji.l4 souein)nd dL£:t0 9 L 90 jeA <br />