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Oti�E'°N WdLO:ti 8lOZ SA ;JJI j paAiaaa� <br />WELLIPUMP PERMIT <br />Sou Jo=ux COUNTY EMVIRO ATENTAL HEALTH DEMTMAWr 1868 EAST HAg -N AVENUE - SMC-RaN CA 95205 - (2:89) 458-1420 <br />NCIN.RFrmmr,,&m F PFRMIT r_AI 1 ignm QS"i-7iiQ7 r-nA IN CPFr^nnmq FYPIRF-, i VFata mnm nnrp ICcI f <br />JOB ADOREss 4901 E Eight Mile RD <br />Cn_yfzfPStockton 95212 <br />99 Frontage R c} <br />CROSS STREET p, � <br />PARCELSZEZLaxQ USE APwJCATwK N <br />G.,ERNA. Tom Reyes <br />p,m,209-679-4026 <br />OWNER ADDRESS '4 9 01 E Eight % i l e R d <br />CMISTATE2 t o c k t o n CA 95212 <br />CONTnAmR Purviance Thrillers, Inc <br />Prim, 209-897-3554 <br />CQNTRACTOR ADDRvw PC Boa 64 <br />CaYISTATEMPL i n d e n, CA 95236 <br />SL'RCOUTRACTDR <br />PRONE <br />SUBCONTRACTOR AQDRE99 <br />CTiYISTAIEIZIP <br />LICENbr X GSI O "I II D-09 U 011net NtiMEPt E)WRAMON DATE <br />0c&msnc WF1L SAt1PuKc3_ II General Mneral/Coliform Bacteria (4391) ,F Dibramochlompropane (4392) –_ Arsenic (4393) <br />IwrEIIDEDUSE OaanesticJPrivate RnigauonJAgrlatihial C Induntrial C Water Ouarrly Momlonng 0 Soil SamplinglChaacterbrabon <br />O Public V.Fnw System <br />If dile rrJa (Lem Ownu. vftersyslem Kanre <br />Cwtad NamerT %orrt NvmW <br />TYPE OF WORK ❑ New Well C Repleeemeni Web C Well Aft2gcNModjffcgdon f) Other <br />6 MOn(toting WeH(5) # of wets G Sob Borhtg(s) <br />scirbod ss f,- Geotechnical o of nargs <br />D OatCfSeTvice Well C Out -Of -Service VM <br />Renewal II Crass -Connection Repair }_ <br />$qN <br />U New Pump V,!Pump Replacement G P.9 Repa, <br />0 Raise Well Casi <br />WELL COUSTRIrCtION <br />DrillingMeth od o Mud Rosary C Air Rotary ❑ Auger 0 Cable Tool D Push Point 0 Other �1(T <br />Proposed Well Depth ft Ez®vauan in diameter <br />C Open Boticm O Grave! PaWGravei Sae in drameler <br />D CwiduchorCasmg mdiameler I Conductor Casing <br />Depth fl <br />Well Casing Diameter_ in ThlcknesWGaugeIASTM Sched <br />7 Steel 0 Plastic ❑ Stainless Steel 0 Other <br />Grout Seal Depth R D Neat Cement (94 lb bag&10 gal wared <br />D Satd Cement sack rrtul7 gal vrater <br />❑ BentonHe(20%Bonds) 7 Dlher <br />Grout Placement rdethodCRmped uFree Fall 0Other <br />ORetardarttlAOceteraitor(name) <br />PEDESTAL Installed By G Driller 0 Pump Contractor C Olhar <br />11 Concrem Pedestal ❑Dimensions: V'Adth ft Length <br />fl Thick in .7 Christy Bo: 7 Stove Pipa <br />Lew, SubmersiNeO Turbine 0 Other HP <br />Pump Set fl Stbndin Wale Level ft <br />I HEREBY CERTIFY THAT f "AVE PREPARED THIS APPLICATTON AND THAT THE WORK WILL BE DONE rN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS. AND RULES AND REGULATIONS- 1 ALSO CERTIFY THAT MY REOUIRED LICENSE IS <br />CU ACt'VE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br />W ERS COM SATION LAWS. <br />M 24 NCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209) 953-7697 <br />Sic. ;�? � T4orporate SecretarUATE <br />Appbct idn Accepted BY <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />�A MEN7 U E NLY <br />Date `lIArea lynplayee 1RY <br />Date PECIAL WeU Playmit <br />T <br />Date t' U W muzRecehred <br />Date Constructed Well Depth it <br />(ala l%87)DEDD <br />WELL TFJIEP PERM <br />m <br />n <br />0A ylo� <br />eNr <br />C�OVP® <br />/ 20, <br />OtiMF OUNn, <br />�EpgR HENT <br />a <br />Z.'d �L9£L8860Z out sla11ilQ aoueinand dZ9 £0 9L SL AeW <br />