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6L9E "N NVES:6 fll0l 8 'unr a(uil paAI;); <br />WELUPUMP PERMIT j <br />► SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1866 EAST HAZELTON AVENUE- SrD xTON CA 95205 . (209) 468-3420 <br />N ON-RFPI INnARI >= Pco.n r w r , <br />.sur <br />ENVIRON <br />PERM <br />--- --- ��� cnrrlccJ I TFJiRFROAIDATEISSUED <br />JOeADDRess 6q32 E Main St crr6Zr Stockton 95215 <br />CROSS STREETN P 4T W a t-p.r R rj APNA 3!0 —Prl PARCELSIZE 0 AND USEAPPLOCATION p <br />OWNER NAME Jim Wunderlich PHONE 209-403-1547 <br />OWNER ADDAESS 6 9 3 2 C l'1 a 1 Tj ,.7 t CITY/$TAT JZP Stockton CA 95215 <br />CONTRACTOR Purviance Drillers, Inc PHONE 209-887-3554 <br />CONTRACTOR ADDRESS ?0 Box 64 CrtY1STATEIZIPL i n d e n, CA 95236 <br />SUBCONTRACTOR PHONE__ <br />SUBCONTRACTOR ADDRESS CITYISTATEIZIP <br />ucENSE X G57 a G61 D -os ❑Omer NUMBER 377923 ExRRATAJN DATE 7/3i/19 <br />DOMESTIC WELL SAMPLING: 0 General MineralfColirarn Bacteria (4391) L Dibromochloropropane (4392) -3 Arsenic (4393) <br />INTENDED USE QlOo.Trestic/Private O IrTigarion/Agriculb:ral G Industrial C Water Qualityrdenitoring C Soil SamplinglCharacterization <br />O Public 'Nerer System A <br />1fdiremit from Owner Water Syslem Name Conlard Name or Pi).- N.mber <br />TYPE OF WORK ❑ New bVell C Replacement Well U. VMI AlleratioNModification D Other <br />C Monitoring Vde11(s) K of wells O Soil Boring(s) 0 O borings 0 Geotechnical Ircrbndng Q <br />C Out -Of -Service Well 0 Oct -Or --Service Well Renewal 0 Cross -Connection Repair d �' <br />0 New Pump IPPump Replacement Pump Repair G Raise Well Casing`S• wy J <br />WELL CONSTRUCnON <br />DriNingMethod 0 Mud Rotary 0 Air Rotary 0 Auger 0 Cable Tool n Push Point n Other HIC^NV,R0N <br />Proposed Well Depth ft Excavation in diameter 0 Open Bottom n Gravel Pack/Gravel Size Alin darn <br />Cl Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness7Gauge/ASTM Schede l ❑ Plastic O Stainless Steel IJ Other <br />Grout Seat Depth ft ZI Neat Cement (941b bag+- 10 gar wafeh U. Sand Cement sack mxl7 gal waler <br />n Bentonite (20% solids) 0 Other <br />Grout Placement Method C Pumped 0 Free Fall D Other G Retardant / Accelerator (name) <br />PeoiesTAO Installed By 0 Drifter 0 Pump Contactor C Other <br />0 Concrete Pedestal 0Dimensions! Width R Length ft Th�dt in C Christy Box 0 Stove Pipe <br />PUMP VSubmersible❑ Turbine 0 Other HP Pump set It Standing Waterlevel ft <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 1 AM IN COMPLIANCE WITH ALL <br />WO RKE MPENSATIONLA <br />M1 M 24 U A ANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209) 953-7697 <br />SIGN /%L� Tt§orporate SecretardrATE�o—�%—/� <br />AN <br />i <br />Al <br />i 7 I l <br />EP RTMENT U E Y <br />Application Accepted By Dale �Area Employee IDR <br />Grout Inspection By Date 0 SPECIAL Well Permit <br />Pump Inspection By Date ❑ WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth g <br />COMMENTS <br />�■ _ <br />r3.�1/rzs:WFAM!■SIL-�iTilfA1 IG�111'�-..�.�►f�:�� - r.. <br />COO. <br />Z'd tZSCZ9960Z <br />yvEL /POMP PERMIT <br />01 <br />9 <br />e <br />v <br />m <br />m <br />or <br />eFNr <br />veb <br />82018 <br />V COIJN <br />ry <br />FNrAt <br />Rrme,V7. <br />out SaejjiaQ aOueiAind ?VC:60 2 � 80 unf <br />