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401 <br />Wti '"N AVSO:H 81H 'Ll 'daS IWIJ P;AI;3;� <br />WELUPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENI-AL HEALTH DEPARTY.EIVT 1868 FAST HALELTON AVENUE - STCCKTON CA 95205 - (209) 463-3420 <br />NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES i YEAR FROM DATE ISSUED <br />JOBADDRESS 20808 E Comstock Rd crTYr.Linden CA 95236 <br />C,,a S srREET D e In a r t i n i Ln APN Iy1 L PARCEL SGZE'- LO USE APPLICAnON 9 <br />T1 J,., ns <br />Ol1P <br />NERNAME Rn,6I P? 9no Ij -r�Gt�)LU7 d w,«NE209-887-32 6 <br />OWNERADoRess P 0. ' Box 655 c,,jST,,w,kinden CA 95236 <br />CONTRACTOR Purviance Drillers, Inc PHONE 209-887-3554 <br />CONTRACTOR ADDRESS PO Box 64 CffWSTAIVZPL i n d e n, C A 952-36 <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDREss CrTY/STATohp <br />LlcENse N C-57 a C-51 .30-09 0 other NumsER 3 7 7 9 2 3 EXPIRATION DATE. 7/31/19 <br />Domes—TG WELL SAtAPLvj(-- D General Mineral/Callforrn Bacteria (4391) Dibromochloropropane (43921 Arsenic (4393) <br />1NTE14CSD USE 0 DomesticlPnvate irngation/Agncullurai O Industrial G Water Ouatit/Monitoring O Soil SamplingrCharac;erization <br />C Pubk Water System <br />rdiffimnl from Cw r. Water System Name Contact Name or Plvoe Number <br />TYPEOFWORK CNauWei CReplacementWell ❑WellAteralion/Modificalion 7Other <br />J Mcnitonng Wells) Ir Ofvmis G Soil Boring(s) ooraonngs G Geotechnical rAcr dMi, <br />0 Out -Of -Service Well C Opt-Of-Servi a Well Renewal O Cross-Conneclfan Repair <br />VNew Pump Pump Replacement Cl Pump Repair ❑ Raise Wel Casing <br />DrInIng Method 0 Mud Rotary C7 Air Rotary D Auger J Cable Tool n Push Point fi Other <br />Proposed Well Daptb ft FxcavaWn in diameter ❑ Open Bottom G Gravel PacVGravel Size in diameter <br />0 Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter_ in Thlckness/Uauge/ASTW Schad = Steel D Plastic J Stainless Steel J Other <br />Grout Seal Deplh ft 0 Neat Cement (941b ba945-10 gatwaA24 7 Sand Cement Saab rn 7 gal water <br />Q Bentonite (20% solids) J Other <br />Grout Pfau ementiM e thod B Pumped 0 Free Fall D Other D Retardant) Accelerator (name) <br />PEDraTAL Installed By O Diller 7 Pump Contractor Cl Other <br />1 D Concrete Pedestal ❑Dimensions: Width ft Length ttThicc fn -I Christy Box C Stove Pipe <br />PU!ApD Submersible Turbino Z) Other HP Pump Set ft Standing VJaler Lexe; ft <br />1 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 CERT`I Y 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 />bVOR •NSA' <br />MINI M 24 DV�CENO�-TnICEQUIRED FOR INSPECTIONS -PLEASE CALL (209} 953-7697 <br />slaN= T1TSorporate Secretar&A,, _ /7 <br />APpricalan Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />4 <br />P <br />R T Date 77 U <br />L Data <br />Date <br />Date <br />Dale <br />Area Employee IDtf j j <br />7 SPECIAL Well Permit <br />0 WAIVER Received <br />Constricted Well Depth ft <br />C'd VZSCZ9960Z <br />rz9 T28s- <br />w <br />m <br />a <br />1817018 <br />(N <br />�FNTe NTY <br />OUB S1911uQ 9OUeiAand eSC:0� 9� Z L daS <br />