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9SN'°N Wb'LS:II L106 '8 'daS aWll paAIaaad <br />Pf <br />WELLlPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTSENT 1888 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209)458-U20 <br />N-KEFUNDABLE PERMIT CALL(Z09) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />ADDRESS 70 21 N Escalon Bellota Rd Clrr/LPLinden Ca 95236 <br />SS STREE-Po d e S t a APN 69 30 r o l U PARCELS¢524. $"D USE APPLICAmomill <br />IERNAMECrt-ek. 'jdp- Farms PTP M� +. y� T PHoi,2098B73554 <br />IER ADDRESS P.O. *Box S 6 '8 L�q� bR ILIr4 j6 ObtTYrsTATislzil, i n d e n C a. 9 5 2 3 6 <br />TRACTOR Purviance Drillers, Inc. PHor,?09---887-3554 <br />TRACTOR ADDRESS P. 0. B o x 6 4 CITY/STATE/LP L i Ti d e n, CA 95236 <br />:ONTRACTOR PHONE <br />[:TOR ADDRESS <br />Xk G•57 _I Gel l'• D-09 u <br />CnYISTATF%ZIP <br />NUMBER -3Z-7-9-2-3— ExPIRA-n ON <br />GEOGRAPHICAL INFORMATIOIC Coordinates X Y Township__ Range Section_ <br />i✓ITINDEDUSE D DcmesticlPrvatD tnigation/Agricultural D Industrial U Water Quality Moniloring Cl Soil Sam pling/Claracterization <br />U Public Water System <br />IrdienmM lImm Owner, er ys:mN..6o. mr or one r <br />TYPE OP WORK --J NeVj WeII t. Replacemenl Well J Well Alteratlon/ModiflcationLI Other <br />'t Monitoring Well(s) of wells rl Soil Baring(s) tot I'Mngs it Geotechnical tot Mrirof <br />Out -01 -Service Well 11 Out -Or -Service Wert Renewal n Cross-Connec'Jon Repair <br />New Pump 'A Pump Replacement r PumD Repair n Raise Wei Casina <br />DriNing .Vathod J Mud Rotary L Air Rotary J Auger Ll Cabe Tool I Push Point U Other <br />Proposed Well Depth fl Excavation in diameter 7 Open Bottom rl Gravel PacklGravel Sae in Orameter <br />!! Conductor Casing in diameter J Conduclor Casing Depth ft <br />Weil Casing Diameter _ in Thickness/Gauge/ASTM Schad _ Steel ri Plastic - Stainless Steel F Other <br />Grout Seal Depth fl Neat Cement (94 lb bogr5-10 gat water) LI Sand Cement sack mivJ7 gal kaler <br />n Bentonite (20% solds) n Other <br />Grout Placement Method G Pumped L Free Fell n Other .- Retardant /Accelerator (name) <br />PEDESTAL Instailed By ❑ Driller LJ Pump Contractor _ Other <br />Concrete Pedestal LDimenstons:Width ft Length ft Thick in ! ! ChristyBox J Stove Pipe <br />Pump _.i Submerslbl�Turbine a Other HP Pump Set_aZ20 ft Standing Water Level it <br />1 HI <br />HEREBY CERTIFY THAT 1 HAVE PREPARED TS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />1OAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS- 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN OOMPLIANCE WITH ALL <br />WOENSATION <br />MINI PA 24 DV CE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209) 3-7697 <br />SIGNED _ �-G>7?'Gc T•ITLEC O r p Secretary DAA — <br />r <br />>R-� EPARTMEN�T% USE ONLY ���/�t—P j� `' 1 <br />Application Accepted 871W ' /i/ Date 1 ' 0 l Area--jr F -— Employee I ON <br />Grout Inspection By Data J SPECIAL W911 Permit <br />Pump Inspection By A60W iaookAhMg k I%&,)4Date � � �) / � � o W/uVER Received <br />Sail Boring Inspection ByDate Constructed Well Depth ft <br />COMM <br />Pit <br />PE <br />Codes <br />Sc Reeefved <br />Info B <br />Check0m <br />ash <br />Amount Date PermiU Invoice WelllQk <br />Remitted Service Re uest 11 <br />43s1 <br />ERDCS-0e <br />403OM2 <br />9•d tL5£L9960Z <br />Gax 6/3zs:D <br />N'EU,FUFY PE91WT <br />W <br />rrI <br />0 <br />Cm <br />cc <br />1%? <br />C= <br />out siellij4 eoulauund e£5 L L L L 80 daS <br />