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OSOti '°N WdW2[02 'LZ '2ny awil paAi <br />WELUPIIMP PERMIT <br />Sn» JOAQUIN COUNTY ENMONMENTAL HFALTN DEPARTMENT 1868 EAST HA2ELTON AVENur • SrocKTON CA M203 - (2n9) 468-5421) <br />NON-RFcrtemawr F p ., rnwr r ...r.r.. „ <br />-• -- --- -^. — I -- —.— T TEAR FROM UATE ISSUE <br />JOO ADDRESS 19580Patterson OT./zp Stockton CA <br />F 526 <br />CHosSSTREEr/-��/— N2 PARCEL51a LANoUseAPPLCAnoN# <br />owrIER (`NAME Da Oill mi nQo pNaNE209-931-5230 <br />IowNEFrADORFss 1958 .Patterson Rd cr,,sTAwz..Stockton CA <br />CnNTAACTOR Purvianee Drillers, Inc PRONE 209-887-3554 <br />CONTRACTOR ADORFss ?0 R o x 64 Cn wBTAT>=lzIPL i n d e n, CA 95236 <br />SUBCONTRACTOR PHONE <br />SLMCONTRAC70R ADDREss Crry/STATMMP <br />LICENSE C-67 L C-61 J D -a9 D Other NUMeI?R 377923 EXI9RAMON DATE 7 / 31 / 19 <br />DOMESTIC WELL SAMP>_ING:O General Mineral/COlifu n Bacteria (4391) -- Dibromachlompropane (4392) - Arsenic (4393) <br />iNTENOED USE @ OOrnestidPrivate 0 Irrigation/Agrirulitural C Industrial 0 VVater Quality Monitoring 0 Sal SamplinglCharaclenzation <br />O Publ,c WaterSystero <br />Ir ffiAerera hom Ormer: WeerSoem Name Contect Name or Phone Number <br />TYPE OF WORK D New Well C Replacement Well D VVd "eratiordModifleation 7 Other <br />r7 Monitoring Wells) 6 Of wells O Soil Boring(s) ° 01 herirgs 0 Geotechnical a 0lbodnp <br />D Out -Of -Service Well 0 Out -Of -Service Well Renewal 0 Cross-Cannection Repair <br />New Pump P Repilacernent ' PLxnp Repair 0 Raise Well Casin <br />WELL CONSTBuCTION <br />'Drilling Method n Mud Rotary n Air Rotary D Auger 0 Cable Tool 0 Push Pant n other <br />Proposed Well Depth ft Excavation in diameter 0 Open Bottom C Gravel PacVGravet Size in diameter <br />E Concluder Casing In diameter , Conductor Casing Depth R <br />Well Casing Diameler _ in Thickness/Gauge/ASTM Sched C Steel D Plastic U Stainless Steel 0 Other <br />Grout Seal Depth ft ] Neat Cement (94 Ib bagM—lagal wafer) 0 Sand Cement sack rrrbd7 gal water <br />C Bentonite (20% solids) ❑ Other <br />Grout Placement Method U Pumped n Free Fall 0 Other C Retardant /Accelerator (name) <br />P EnrsTAL Installed By 0 Driller 0 Pump Contractor C Other <br />C Concrete Pedestal ODimertslona: Width It Le I I ft ThIckr in n Christy Box D Stove Pipe <br />&-hT 10 Submersibie0 Turbine ❑ Other HP Pump Se A Standing Water Level tt <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND HAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQWN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />PENSATiON <br />MWI M 24 D NCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209) 95 -7697 <br />sl6 T, orporate Se( etar <br />. I e <br />f)EPjRTMENT.lUpSE QfNLY Q <br />Application Accepted By Date 00 Area <br />Employee IDIY <br />Grout Inspection By Date I 1 � ❑ PECIAL WQII Permit <br />Pump Inspection By Date /�L /�1--rIT- i1 WAIVER Received <br />Soil Boring Inspection By Date Constructed Yell Depth _ H <br />COMMENTS <br />:g <br />I� <br />EIVED <br />" 2058 <br />HEALTH <br />ti� ?4918 <br />t <br />9Fr�rgr'1'�Y <br />WELL(PUMP PER MT <br />£-d VLSCL9960Z out sielliaa eoueimnd dZ 6:t o 91 LZ 6nV <br />