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cFZO'°N Wdl� l PIOZ 'ally aWlj PaAl;°;� <br />0 WELL/PUMP PERMIT q <br />SAN JOAOUIN COUNTY EN4RONMENTAL HEALTH DEPARTMEIT 1B66 EAST HAZELTON AVENUE- STOCKTON CA 95205 - (2C9) 46&34ZD <br />NUN -KE FUN DABLE PERMIT CALL (ZUUI 95:1-iFD9i FOR INSPECTIONS tAl'IKtJ T YEAR FROM DATE ISSUEL <br />JOB ADDREm1 �9qS F Htcy 26 ctTr178 Linden CA 95236 <br />CROSSSTREET M u r r a R d APN ' I PARCEL-S� LI ANDi EAPPLrcAn ave <br />cru,,;,,,Roy Fowler PHotrEa9-887-3y49 <br />❑wrier AoaREsS" 4 0 c,T,a <br />5 N F d i s o n S t /SAri� sTA,FrbrS t o c k t o n CA 95203 <br />CONTRACTOR Purviance grillers, Inc PHONE 219-897-3554 <br />CONTRACTOR ADDRESS PO Bog 64 GITYISTATEOPL i n d e n, CA 95236 <br />SVBCDrr-TRACTOR PHONE <br />A ADDRESS CITYISTATEIZg_ <br />C-57 U "I 0 1109 U Other NUMBER EXPiRAnON <br />DOma.-vnc WELL SAMPLING: c General Mi neraUCofiforTn Bacteria (43 911 . 0 ibrorr.ochlom propane (4392) Arsenic (43 93) <br />INTENDED USE • DomeSIlCJPrivate ❑ lndgationtAgricudural C Industrial C Water Quality Mordtoring O Soil Sampling/Characterization <br />C Pubrlc Water System <br />If®reran: f�vm Owner. Mater System iln Cont ed Nara of Pilorx Number <br />TYPEOFWORK ❑ NeW Wdl ❑ Replacement Well C Well AlieraliorYtdodificabon O Ofher <br />❑ Modwringwen(s)_ cotwvLS C SDa eoung(s) 9� n Geotechnical rofbcmgs <br />❑ Out -Of -Service Welt C Out -Of -Service: Well Renewal ❑ Cross -Connection Repair � <br />❑ New Pump 0 Ptffnp Replacement ❑ Pump Repair ❑ Pig se Weft Casino <br />1 W ELL CONSTRUCTION <br />Drilling Method ❑ Mud Rclary C Air Rotary ❑ Auger ❑ Cable Tool 5 Push PDlyd ❑ Olner <br />Proposed Well Depth ft F=avadon in diameter - Open Bottom G Gravel PacluGravel S¢e in diameler <br />Cl CorductorCasing in diameter / Cond:,cter Casing Cepth It <br />! Well Caging Diameter_ fn ThIemess/GaugeIASTM Schell C Steel ❑ Plastic C Sta"ess Steel ❑ Other <br />Grout Seal Oep!h fl O Neat Cement (941b twg3-fO gal water) U Sand Cement sack rnbrr r water <br />Cl Bentonite (20% Solids) ❑ Other <br />[Grout Placement Method C Pumped C Free FaU J Other G Rfea ant / Acceierator (name) <br />i PEDESTAL Installed 8y ❑ Driller 3 Purnp Contractor ❑ Other <br />❑ Concrete Pedestal CDimensions: Wrdth fr Length ft Thick in n Christy Box n Stave Pltpa <br />P <br />APR <br />Sw jVr <br />E�1R <br />a= r Submersible0 Turbine D Other HP Pump Sel==J ; 1_I R Standing Watei Level t ZZ:j fl <br />I HERESY 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 W COMPLIANCE WITH ALL <br />24 H i2 V CE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209)3-7697 <br />'JG corporate SecretaryA�-�� <br />ge P A TM E NT US CVNJ, Y <br />Application Accepted By g, Dale -` AreaEmployee ID# <br />Grout inspection By C.'. t7 PECIAL Well Permit <br />Purnb Inspection By Dale ` ❑ WAIVER Received <br />Soil Boring Inspecfien By Date Corv"mcted Well Depth it <br />COMMENTS <br />NO <br />"�. <br />i�iclli��7►!//:�JI/J����C��e//1�11�� t ' <br />V k- / �7Z7,7 7,,/-7S—l%TLLIPUVPPEM7 <br />:JID 4S -Ga aPJTna <br />m <br />n <br />b <br />P <br />v <br />z <br />oo <br />0 <br />�m <br />M nn? <br />F <br />C= <br />M <br />7, d tZ( EU9960Z out S.1811!.lQ aoueiA-md d6L:Z0 2L f;0-Idy <br />