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KSZ'IN AVU:01 LIOZ 'L "IN awil paAAI;3;�' <br />WELL/PUMP PERMIT P <br />SAN JOAQUIN COUNTY ENVSRONMENTAL HEALTH DEPARIRAENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)466-3420 <br />NCIH-KEFUNDABLE PERMIT CALL 2U9 953-7697 FORINSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />Joa ADDRESS 19540 E Flood II CITrmp , i n(Len CA 05230 <br />CROSS STREEI T—,AI• F/u od APN - 0V PARCIELSIZE LAND USE APPLICATION # <br />OWNERNANu! A&R DalPorto Ffi&W INC P,,209-484-8554 <br />OWNER AODRESS P.O. Box 147 c,TrsTATErzIP Linden Ca 95236 <br />CONTRACTOR' Purviance Drillers, Inc PHONE 209-887-3554 <br />CONTRACTOR IAODRESS p 0 Box 64 CHYISTATEidPL i n d e n, CA 95236 <br />ADDRESS <br />LICENSE Y, GSI O C-61 Ll MS) U Oth <br />PHONE <br />CITYfSTATE0P <br />NUMBER �'•� EXPIRATION <br />DOMESTIC WELL SAMPUNG. ❑ General Mineral/Coliform Bacteria (4391) t- Dibromochloropropene (4392) 7 Arsenic (4393) <br />INTENDED USE 0 DomestiCiPrivate yinigationfAgricutural C Industrial O Walei-Quafity Monitoring O Soil Sampling/Charectetization <br />❑ Publ ic'Nater Systmr <br />lldifr—rtirom Owner. watar5ystem Neme Cantnq Nam or Phone Number <br />I YPE OP WORK C New Well U Replacement Well G Well Alteration/Wdfication n Other <br />D Monitoring Well(s) 4 of wells C Sal Borings) aor b"n9a n Geolechnical sorborings <br />G Oul-Of-Service Well C Out -Of -Service Well Renewal D Crass -Connection Repair <br />❑ New Pumo VPumo Reolacament r- P:mn Repair n P, ci— WAIT <br />Drllling Method D Mud Rotary D Air Rotary 0 Auger D Cable Tool C Push Pohl ❑ Omer <br />Proposed Well Depth N Excavation in diameter -1Open Bottom D Gravel Packn3ravel Size in diameter <br />❑ Conductor rasing indiameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thidmess/Gouge/ASTM Sched 7 Steel ❑ Plastic ❑ Stainless Steel D Other <br />Grout Seal Depth ft U Neat Cement (94 1b bag,' -10 gaf water) 7 Sand Cement sack mu/7'gal wafer <br />D Bentonite (20% solids) D 011ier <br />Grout Placement Method 0 Pumped 0 Free Fal) 0 Other G Retardant I Accelerator (name) <br />PEDESTAL I Installed By ❑ Driller C Pump Contractor C Other <br />LConcrete Pedestal nDimensions:Width - _ft Lenath it Thick in nChristvBox nStovePlna <br />PUMP S SubmersibleO Turbine 0 Other _ _ HP_ I() Pump Set 1 ?s 7 n Standing Water Level j= 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 15 <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE V%1 TH ALL <br />WORKZRS4-OMPENSATION LAWS. <br />NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />• -corporate SecretaryAT, 11-7-/-7 <br />!n <br />m <br />v <br />A <br />15: - <br />------------- <br />■■fit■■■■■!■■i��+�G■■■ail■■■■■■■■■!rI!ir■■■■■a■■■■■�.: <br />■■■■■■■■■w■`-.■■■■■■■■■■■■■■■ante■■■■■■■■■■■■� <br />■■■■■■■■ES'ia�■■�S�■��■aa■a�►��ll�ir■■E■■■■■■■!■E _ <br />��iiiii�:iiii■ iiiiiiiiiiii��i�iii■iiiiiiiai <br />■a■■■■■to■saiiaiiiiia■■■■■■■■■■■■■■■■■® W <br />./l. r <br />- <br />��rr <br />LFI04306 MVIG 2 _ .�/O /p i "`7 ) WELL IFLMP PERMIT <br />Z'd VZSCZ2960Z out sjell!j4 eoutai/und IROL: L L LL LO AON <br />