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6ti "N NV[ti:ll 206 'L6'tidy ;Wli paAI;39� <br />WELLIPUMP PERMIT 1 <br />SAN JOAQUIN COUNTY ENVI iONMEWAL HEALTH DEPARTMENT 106$ FAST HAZE -TON AVENUE-STOCKTON CA 95205 - (209) 4+6&3420 <br />NON-REFUNDABLE PERMIT CALL (209) 963-7697 FOR INSPECTIONS IJIt'IKtS T YEAR FROM UATE I55uCu <br />JOBADOREas 5800 Duncan Rd Cjz, Linden, CA 95236 <br />CROSS STREP, B a k e r Rd AP �� PARn, <br />CEL SIZE LAND USE APPLICATION A <br />OWNER NAME Jim Ca m i n a t a PHONE 2oh- �i7I —6/7V <br />OWNER ADDRESS POBox 1468 , CR,/STATFIZ,pLinden, CA 95236 <br />CONTRACTOR Purviance Drillers, Inc p1IOKE 21719-887-3554 <br />CONTRACTOR ADDRESS PO Box 64 CITYISTATV ,PL i ride n, CA 95236 <br />c,rcrrwtner-xw PHONE - <br />3CONTRACTOR ADDRESS CITY,STATEf Zip <br />ENSE X C-57 _ D CG61 110-09 G Other NUNIBER 3 7 7 ) 2 3 EXPIRATION DATE 7/ <br />DOMESTIC WELL SAMPLING: rl General Mineral/Coliform Bacteria (4391) C Dibromcchloropropane, (4392) 7 Arsenic (4393) <br />INTFNDED USE G Domestict-Private XIrrigation,AgriLvBural 0 Industrial u Water Quality monitoring D Soil Sampling/Characterization <br />LI Public Water System <br />itdroereet tnm Owne- Weser System Nam Carders Nems or Phone Number <br />TYPE OF WORK D New Well D Replacement Well C Well Alteration/Modifica ion D Oliver <br />O Monitoring wall(s) 4 o wells C Sail Borkv(s) aotbnrnB n Geolechnicat sorborings <br />D Out-Of-Seroce Well D Out -Of -Service Well Renewal D Cross -Connection Repair <br />r _ _ r17 New Pumo k Pump Replacement C Pump Repair D Raise Well CasinE `yYN j <br />Drilling Method E Mud Rotary ❑ Air Rotary 7 Auger D Cable Tool D Push Point D Other "CAI <br />Proposed Weil Depth ft Excavation in diameter D Open Bottom G Gravel PacWGravel Size in darneter <br />D Conductor Casing in diameter I Conductor Casing Depth it <br />Well Casing Diameter - in ThicknesWGauge/ASTM Silted [i Steel 7 Plastic 0 Stainless Steel ::] Other <br />Grout Seal Depth n D Neat Cement (94 lb bagY5409art4ater) 7 Sand Cement sack rrrx17 gal water <br />D Bentonite (2D% sonds) D Other <br />Grout Placement Method G Pumped 0 Free Fall 0 Other 0 Retardant I Accelerator (name) <br />PEDESTAL Installed By G Driller 0 Pump Contnaetor ❑ Other <br />D Concrete Pedestal C Dimensions: V%kdth m Length ft Thick in D Christy Box 0 Stove Pipe <br />PUMP n Submersible Turhirs 0 Other HP /Oa Pump Set./ 0 ft Standing Water Levei <br />I 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. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS - <br />M 24 VANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED Tnsorporate Secretarl3'ATE4/27/18 <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspecticn By <br />Sail Boring Inspection By <br />COMMENTS <br />ra <br />g <br />m <br />PA <br />�Pftr-..�' v / <br />2018 <br />A(7AL <br />ARrMFNt <br />.I VED <br />72018 <br />?Aa zIPA ", <br />I P R T M E N T U E O L� <br />Date (J}[ <br />Area -,,�— j-� E,npbyee IDp <br />Date <br />El SPECIAL Well POrrnit <br />Date <br />❑ WAIVER Received <br />Date <br />Constructed Well Depth <br />n <br />EH043-06 M1116 <br />Z'd VL99L9960Z <br />� <br />17 -e 78/17713 8 - <br />WELL (PUMP PERNn <br />out s_lejjuQ aoua/und e/ Z: L L 9 L LZ AV <br />