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8ti1� 'oN Wd�Z ti 8l Z 8l 'J os auiIl paAIaaa� <br /> INELLIPLIMP PERMIT <br /> SAN JOAOIIIN COUNTY ENVIRONMENTAL HEALTH DEPARTAItNT 1869 EASTHAzaTaN VENUE-SMCKTON CA 95205-(209)469-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES i YEAR FROM DATE ISSUED <br /> JcaADDRESScjz,,Stockton CA 95215__10419 F llu�g 26 <br /> m <br /> n <br /> mossSTREE 3-_ AV[r- AP N t�30' PARCELS2E •Z LANDLIsEAPPLCanDNO n <br /> O 925-784-9493 m <br /> wNeltNAroE ( Nr; kQ a r�tl l l a � �"/'I (G C- T� PHONE <br /> Or47NER ADnRFss 10 4 1 9 R 14 w 3r 26 CIIYJSTATEfZ,P S t o c k t o n C A 9 5 2 1 5 <br /> CONTRACTOR Purviance Drillers , Inc PHONE 209-887-3554 <br /> Cav,RACTOR ADDREss PO- Box 6 4 C,ndsrwm2,PL i n d e n , CA 95236 <br /> SUBCONTRACTOR PHONE <br /> ,SURCONTRACTOR ADDRESS CTYISTATE tP <br /> LIL,:r,sE C-S> U C-61377923a aos D omtr NuMat�t F�cPIruTION DATE 7/31 /19 <br /> DOMFSTTC UIfrkL SAmPLGIG:C General Mineral/Callfban Bacteria(4391) Dibron'lochfDropropane(4392)D Arsenic(4393) <br /> INTENDED Use 0 Dome3tiCiPrivate ,rrTigationfAgricultural C Industrial 0 Water Quality Monitoring D Sort SarnplinglCharacterizalion <br /> D Public Writer m <br /> I(d4*mn1rmm0wrmc %XerSystem Name Coded NanesaPeene N.Mm, <br /> TYPE OF WORK 0 New Wes C Replacement Well 0 Well Alleration(Modification Q Olher <br /> 0 Monitoring Well(s)-#of wells G Soil Boring(s) sormnlg G Geotechnical nor 06619s <br /> O Out-Of-Service Well c Out-OfService Wdl Renewal C Cross-Connection Repair <br /> D New Pum G PUMP Replacement PLL Re air 1 e 0 Raise Wall Casing <br /> WELL CONSTRUCTION T �Dr a" <br /> Drilling Method D Mud Rolaty r AirRotay D Auger 0 Cable Tool 1 Push Point 0 other <br /> Proposed Wefl Depth It Excavation n diameter C Open Bottom C Gravel PaWGravel Size in diameter <br /> 0 Conductor Casing in dierneter J Conductor Casing Depth R <br /> Well Casing Oiamefer_in ThIcknessJGaugeJASTM Srhed =Sled 7 Plastic C Stainless Steel D Other <br /> GrautSeal Depth ft DNeat Cement(941bbag5-Togat theter) USand Cement lackmal7gal water <br /> 0 Benton ile(20%solids) 7 Other <br /> Grout PlacementMethodCpumped 0Free Fall ?Other 7Retardant IAccelerator(neme) <br /> PEDE3T.gL Installed By 0 DAIIer 7 Pump ConUactor D Other <br /> LT Concrete Pedestal GDimensiorm:b'ttdVl ft L27 ftThick in :-IChristy Box ❑Stove Pipe <br /> Pu, SubmersibteO Turbine 0 Other HP Pump set ft Startr4ng Water Level ri <br /> I HEREBY CERTIFY THAT 1 HADVE PREPARED THIS APPLICATION ANTHAT 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 /> CURREfVT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WO ATION <br /> 7MIRNIU-424 V CE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209 953-7697 <br /> SIGcorporate Secretar�„T� q -t� �����r"9W <br /> 'P LA SEP <br /> i <br /> VIRONMENTAL HEALTF <br /> ` 7 PERMIT/SERV(3FS <br /> i <br /> It Ir <br /> v I <br /> I <br /> i <br /> EP RTMENT U EINLY `�/��9'/�/Application Accepted By JPA A--T'`�t— Employee <br /> S <br /> Grout Inspectmn By Date 1 PECIAL <br /> We <br /> Pe[Trll[ <br /> I -Punp Inspection By RM Date 1 L ❑ WAnmR Received <br /> Sal Boring inspection By Date Constructed Well Depth ft elf <br /> COMMENTS <br /> ,r tU18 <br /> PE SC Received Amount Date permit/ Invoice 'JJryl N <br /> C es Info _ _ _ _ _ emitted S ice Ra nest to <br /> 7 <br /> rH ,rAL <br /> Ef"'J CS.e" PA1n6 tY1LfPl,'AfP?ERI.1fr <br /> Z'd VL9U9960Z out wattle(]GOUeiAlnd d99:E09L 2L deS <br />