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C91� '°N AdS� EH '9 'JCA "'i PaAI ;39� WELLIPUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EASTHAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 NON-REFUNDA13LE PERMIT CALL'209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED Joe ADDRESS 217000 7000 E Flood ^R'd c,ry/z,P Linden , CA 95236 m CROs STREET VGL� APN U y 3—3 1 O— ? PARCEL SIS USE APPLICATION g OWNER NAME Shelton Rd an PHONE 2n9-351 -1 ?�n OWNER ADDRESS 186012 Tobacco R d aTY1STATEMP Linden . C A 95236 CONTRACTOR Purviance Drillers , Inc PHONE 209-887-3554 CONTRACTOR ADDRESS PC Box 64 CrTyiSTATEIZPL i n d e n, CA 95236 SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATEMP LICETL9E 'CS/ Cl C-131 D D-09 D other NUMBER 377923 EXPIRATION DATE 7/31/19 Domesnc WELLSAMPUNG:C General MineraUCol thrm.Bacteria(4391)C Dibromochloropropane(4392)=Arsenic(4393) INTENDED USE O DoriesticfPrivate Irrigation/Agricultural Q Industrial C Water Quality Monitoring ❑Scil Sampling/Characterization D Public Water System Ildi[ereMGOm Owner. Water System Name Contact Name wPbon.Number be, 0New Well C Replacement Well D Well Alleralton/MocKcatim D Other •' C Monitoring Well(s) #of wells n Soii Bonn •or bo^ g(s) "� D Geotechnical _Rol Wnlras D Out-Of-Service Well [U Out-Or-Service Well'Renewal ❑Cross-Conne Wn Repair ,e� ew Pum C Purnp Re iecernent D Pump Repair 0 Raise Well Casing ' v WELL CONSTRUCTION Drilling Method n Mud Rotary C Air Rotary ct Auger r Cable Tool D Push Point O Other '�— Proposed Wall! Depthfl Excavation in diameter M Open Boftom n Gravel PacklG avel Size h�d[a� r �O�VR D Conductor Casing in diameter ! Conductor Casing Depth ft N p CpV Well Casing Diameter_ In ThieJcnesslGaugeIASTM Sched G Steel 7 Plasfic D Stainless Steel ❑Other � N Grout Seal Depth ft D Neal Coolant 04 1b bapSlOga/water) 1 Send Cement sack ftxr7 gal vYa D Eentonite(20%solids) D other FNT Grout Placement Method C Pumped D Free Fall D Other D Retardant/Accelerator(name) PEDESTAL Installed By D Driller D Pump Contractor D Other 3 Concrete Pedestal ODlmenslons:Width ft length ftThick In f,Christy Box D Stove Pipe PUMP .G Submersitu - urbine 7 Other HP= Pump Set fl Slanting Water Level It I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATLONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WI E CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN CCMPUANCE WITH ALL WO ENSAllO WS. MIN IM 24 D NCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 SIGNE �,,§orporate Secretar�/ L7ATE G CEI VIEZ i A i w NMENTAL N MJI-ISERLAr E.4 LH o I a� I i FS I I EPA TMENT SE NLY ////////`7/'�/,�J- Application Accepted ByAm— Date Area Employee 1Dk,-,�'�'�'--F Grout Inspection By Date PECIAL WQII Permit Pump Inspection By Dale ❑ WAIVER Received Soil Baring ertbn By Date Constructed Well Depth It COP MENTI 1 L L PE SC Received Check#/ Amount Permit/ Codes Inco B Cash Remitted Date Service Request At Invoice# well IDN 1 EHO41-06 9n7111e7G3�-o,33 WELL TL/,IP PERkrT 4'd �L9£L8860Z oul saa111aQ eouelnand d8£:V0 96 90 JeA