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6EE '°N Md : Z 8[OZ �6 ,pj IWI J paAI@D;� <br /> WELL/PUMP PERMIT s <br /> ~ SAN JOAOWN COUNTY ENVIROMMMIrAL HEALTH DEPARTMENT 1663 EASTHAZELTON AVENUE-STOCKTON CA 95205-(209)46"20 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB At) 9072 N Hildreth Ln crP Stockton CA 95212 m <br /> DTYrz1 <br /> CROSS STREET /If e ti ka APN PARCEL.StzE_ _LAnD UsE APPUcanO N it <br /> OWNER NMtESteveSolari %om 09-423-9522 <br /> OWNER ADDR �7 <br /> ESS9072 �V Hildreth Ln CnY/STA,,0,Stockton CA 95212 <br /> CONTRACTOR Purviance Drillers , Inc PHONE 209-897-3554 <br /> CONTRACTOR ADDRESS PO Box 64 CrrYISTA,Em,L i n d e n , CA 95230 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CRYISTATEOP <br /> LICENSE C57 0 Cbl 0 D-09 V Other NUMBER E)mitwION OAT£ <br /> Dam s,nc WELL SAmPUNo:0 General Mineramoliform Bacteria(4391)C Dibromochloropropane(4392)7 Arsenic(4393) <br /> INTENDED USE F#DomestclPrivale C IrrigafloritAgricu lural G Industrial G WalerOuality Monitoring 0 Soil SwiplingrCharactenzaton <br /> C Pubric Water System <br /> Irdffererl rmn Owner, Water Slstem Name Cafftact Name or Phan[Number <br /> TYPE OPWORK 0 New VV61 0 Replacernent Well C WeD AlterationlModificalion 0 Other <br /> 0 Monitoring Weii(s) of yells G Soil Baing(s) son bunngs n Geotechnical sot bonngs <br /> 0 Out Or-Senvlce Well O Out-OfService Well Renewal C Cross-Connection Repair x <br /> 0 New Purnia Cl Purrip Replacement Z Pump Repair a Raise Well Casinil <br /> WELLCONS'MUCIMN <br /> r <br /> Drilling Potethod C Mud Rotary C Air Rotary 0 Auger n Cable Tool 0 Push Point ❑ Other <br /> Proposed Well Depth ft Excavation in diameter ❑Open Boftoni 0 Gravel PackJGravel Size in diameter <br /> C Conductor Casng in diameter I Condumr Casing Depth ft <br /> Well Casing Ciameter_in Thidmess(GaugeIASTM Sched D Steil O Plastic O Stainless Steel n Other <br /> Groat Seal Oepth N D Neat Cement(94 Ib baYS-10 gof rarer) 0 Sand Cement sack rnW7 gal vrater <br /> C Bentenite(20%solids) ❑Other <br /> ,Grout Placement Method 0 Pumped n Free Fall 3 Other D Retardant/Accelerator(name) <br /> PEDESTAL Installed By 0 Ori{ler 0 Pump Contractor O Other <br /> C Concrete Pedestal ODimensiorts:Wrr'th f: Length R Thick In 0 ChristyBots1 §gEd <br /> PUMP Sutrnersible0 Turbine 0 Other I g' Pump Set fl Standing Water Level <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE VWTH SAN <br /> JOAQUIN 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 COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAW <br /> MINI 24 t NCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> corporate SecretarLyA, <br /> I t <br /> f t74 <br /> I 1 <br /> i <br /> I <br /> I <br /> R gUj Go U-1 veb <br /> YtijENT <br /> M LU I Ee 2 6 2018 <br /> a~ � � AQUI CO <br /> V RO " U <br /> LLIm IY LL Application By D PART Date T S E ��7,L}Y �aPloyee IDRt LT M D PAR�MFNr <br /> 5 n �� '_ <br /> Z <br /> Grout inspection By Date D SPECIAL Well Permit <br /> w 4 <br /> Pump tnspec5on By Date I U WXVER Received <br /> Soil 8erng Inspection By Date Constructed Well Depth ti <br /> COMMENTS <br /> PE SC Received CheCIGW Arnount Date Perrin Involce# Well IDA <br /> es Info h Remitted Semce Reque,at9 <br /> fH0 2316 9101116 , 755 7 F1,53WELL IPU MP PERM" <br /> CA tZSCZ9960Z 7 out SJGII!.lQ aoueiAind dZ0:E0 9 EZ 9azj <br />