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9tiL6'ON AdLS:� L106 ;ta11 p;Ai;); <br />WE <br />,W �Q' i� SAN JOAQUINCOUNTYE,WIRONNENTALHEALTHDEPAR MENT MP PERMIT P <br />Jr <br />1' NON-REFUNDABLE PERMIT 1868 �THAZELTON AVEfuue - STOCKTON CA 942p5 _ (260) 468-3420 <br />i� CALL 209 963-7697 FOR INSPECTIONS <br />Job AooREss 1 6 � 21 Hwy $ g _EXPIRES 1 YEAR FROM DATE ISSUED <br />CROSS STREET <br />clTYrnP L4ckefora <br />S <br />APN <br />0115 <br />OWNER NAME Ceorg 2 OO PARCELSIZE <br />Alves =AO Use APP+ICATION <br />nO <br />OWNERAODREss 16021 N Hwy 88 :PHONE 209-689-9090 <br />CONTRACTOR <br />Purviance Drillers, Inc CtTYlSTATE/ZIP Lockeford CA 9523 <br />,CONTRACTOR ADDRESS POBox 64 IPHONE 209-887-3554 <br />SUBCONTRACTOR ciTTisTATErztp. Linden Ca 95236 <br />'SUBCONTRACTOR ADDRESS ! PHONE <br />CITY/STATFlJjP i <br />LICENSE LXC-57 =: C-61 7 D-09 ❑ Other N 3779231 <br />NUMBER EmtAnoN DATE 7 / 31/19 <br />1)"Esne WeLL SANPUND; �; General Mlnerallcoriforrn Bacteria (4391) E Dibromoehloropropane (4392) :7 Arsenic (4393) <br />El �TENOCD U$E Public iwater SyastemIrrigation/AgricuRural C Industrial C Waterpuaty Monftodn <br />9' ❑ Soil Samping/Characlerization7t(filReN fan <br />Owner. I <br />Wald System Namo � <br />�E a` WORK .y New YVell Canha Name ur Plgne NEN ber <br />Replacement Well C Weil Ateration/Modilicafion OlI <br />❑ Monitoring We0(s) U Otlier <br />#of wells 0 Soil Borings) Gorda <br />C' Oul-0t-Servica Well ❑l GeO;echrti0el 0 0bcnnps <br />❑ Out -01 -Service Well Renewal <br />m ReplaceCross-Cannedton Repair <br />urs ^^ — 0 NewPumO O Pument ❑ P,,a o_ :. <br />D,Illing r4ethod *Mud Rotary ^ Air Rotary Proposed Well JPe th Z 0 Auger 17 Cable Tool 7 Push Point O Other <br />LGroup _ 3 S R Excavation -E _ in diameter Ir Open BWtom ❑ Gravel Pack/Gravei Size <br />D Conductor Casing in diameter / COndudorC�jrn ,� in diameter <br />t <br />asing Diameter I n�slGauge/gSTM Sched -Mr, 6�pth �_ <br />Seal Depth!- +! Steel ❑Plastic L„Stainless Steel ❑Other <br />J Neat Cement (94 !6 6a9i5-10 gal v�rater) ;b Sand Ceme�l�— <br />❑ Bentonite (20% solids) O Olher sack m!x/7 gal water <br />cement Method D Pumped ❑ Free Fall 7 Other <br />PEDESTAL Installed —� = Retardam /Accelerator (name) <br />BY 'A Driller ❑ Pump Contractor ❑ Owe <br />W Concrete Pedestal 7Dimenslons: Width <br />f1 Length RThidc it D ChristyBOis .7 Stove Pipe <br />Pu 7 SubmersibleD Turbine 7 OtherHP <br />I HEREBY CERTIFY THAT J HAVE PREPARED THIS AP Pump Sexes = h Standing ln,ater Level ft <br />JOAQUIN COUNTY ORDINANCES, STATE PLICATION AND THAT THE WORK WILL ElDONE IN ACCORDANCE WITH SAN J <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND I <br />WS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE !S <br />WORK OMPENSATION LAWS. THAT R AM IN COMPLIANCE WITH ALL <br />MINIM 24 VANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 963-7627 <br />TITLE P <br />Src.veo Cor o r Sect a;ry (20912719117 <br />. I DATE <br />REC <br />f. �r�i�rli�i iii■ii■iiiii■iiiatiiii�iiirF'>:vi■i�ir <br />Ilii!■lilii■iiiiA■■iii■iiiiiiiiilii"i��>•� <br />1l�!!!!li■■■■ii■■i■■■■■■i■f■■■i■■I�i■■■f <br />• � ��,,-,�i;ll/■i■iiiii■■ii■■iiiiii■iiil�ti■ilii/I■E <br />. ' .!�• ,�Ll� ,'�7■ii/ilii'!■ii■■i■iii■i■il■i�f■ii�iill■it: <br />■liii�%F <br />ilk■i■iiilliiliii■iii■iii■■■ii■!illi <br />■Illiiti■I�iVSil■iiipi■■iii■i■1�J���■tl��WRAg:..�� <br />■■■iiVA <br />�1i1L�1�i1■N��I��1.���----- <br />� <br />E ARTMENT US O LY <br />APPIICation Accepted By � � / <br />Grout Inspection By Y Date Area <br />Employee ID# <br />Pump InDate <br />Inspection By Date L7 SPECIAL Well Permit <br />__ <br />Scll Boring Inspection By U :WAIVER Received <br />COMMENTS Dale_ Constructed Well Depth k <br />iWELL -'PUMP PERM,? <br />Z'd VL9£L8860Z out saellija eouei/und dLti:tiO L L 9 L oe4 <br />