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6ELVIN MOVE 8[06 '6[ 'ung awil paAI;3;� <br />WELUPUMP PERMIT <br />SAN JOAQUIN COUNTY ENV RONMENTAL HEALTH DEPARTMENT T aea EAST HAZELToN AV ENU E - ST0CKTON CA SS20S - (209) 468-3420 <br />N-KEFUNDABLE PERMIT GALL ZU75y3J-/b`Jl FOR INWI=L-110NS CAYIKCJ I t tAli t OM VAlt I5Sp/ED <br />ADDRFss 2 Jack n Rd CITY/ZIP T 3 o 1i , <br />i, C a <br />SS STREET Liberty APN '01)1— t 0 PARCEL SUE (Qq. 3 "LAND USE APPLICATION # <br />MR NAME Fred Calosso PHONE <br />IER ADDRESS 83490 S Cove Way CITYISTATEraP Florence, OR 9743 <br />PurDviance Drillers, Inc <br />ADDRESS PO 1, o x 64 <br />)R ADDRESS <br />C-57 ❑ C-61 ❑ 0-09 U <br />PHONE 209-8B7-3554 <br />cITrISTATEIIpL i n d e n, CA 95236 <br />PHONE <br />CFTYISTATEIIB <br />NUMBER 377923 EMRAUO 1 <br />7/31/1 <br />DOMESTC WELL SAMPUNG: D General MinerallColifonn Bacteria (4391) E Dibromochloropropane (4392) --Arsenic (4393) <br />Area Employee IDT <br />INTENDED USE D Domeslic/Privale f�(Irrigahon/Agricultural ❑ Industrial ,-3 Water Quality Monilorng O Soil SamplinglCharacterization <br />❑ Public Wafer System_____ <br />❑ SPECIAL Well POrtnit <br />If dirfemN from Owner. Waley System Nerro Cordon Nene or Pfiane Number <br />TYPE OF WORK ❑ New Wer C Replacement Well C Well Akeration/Modification C Other <br />❑ WAIVER R@CBIVed <br />❑ Monitoring Wells) fb of wells 7 Shc Boring(s) s or bodrps C Gectechnical u of borings <br />( <br />11 Out -OF - Service Well D Ord-O:Service Well Renewal ❑ Cross -Connection Repair <br />4/ <br />D New Pum Pump Replacement = Pump Repair c Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method ❑ Mud Rotary G Air Rotary Cl Auger ❑ Cable Tool -1 Push Point D Other <br />EIV <br />;Proposed Well Depth_A Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Sine in d <br />(Q <br />n ConauctorCasing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter-__- in Thidmess)Gauge/ASTM Sched - Steel ❑ Plastic C Stainless Steel O Other <br />Grout Seal Depth_ft U Neat Cement (94 Ib bag/5.109al wares C Send Cemerd sack rmn gal <br />water <br />❑ Bentonite (201h solids) O Olher <br />Grout Placement Method ❑ Pumped � Free Fall ❑ Other ❑ Retardant f Accelerator (name) <br />(PEDESTAL Installed By O Drlter D Pump Contractor ❑ Other <br />n Concrete Pedestal CDimensions: vMdlh fl Length ft Thick in L3 Christy Box O Stove Pipe <br />Pu- —MP ❑ Submersible Turbine D Olher HP.7 Pump Set ft Standing Waer Level LSA_ fl <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY ORDWANCES, 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 PENSATION 5. <br />MINI A 24 A ANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED �� TaSorporate SecretarEyATE -j S-iF <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boning inspection By <br />COMMENTS <br />N <br />P. <br />A <br />OD <br />m <br />ZE ZEA►i <br />IVSD <br />.IN 212018 <br />p� AfSIOAC 1Y <br />AR -r yENT <br />ED] <br />)EFIARTMENT USY <br />Date I <br />Area Employee IDT <br />Date <br />❑ SPECIAL Well POrtnit <br />Date y <br />❑ WAIVER R@CBIVed <br />If fl <br />Date tJ <br />Constructed Well Depth <br />ft <br />EHDL306 1001/76 <br />ezW. 4 71 3ES,,17 / <br />WELL NUr! P PERMIT <br />C d tZSCZ9960Z out sialp(] eoulamind dot:Z0 96 6L ung <br />