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6SH A WdK :: BM H '"Pr awil paAl ;3;� <br /> r <br /> t <br /> WELL/PUMP PERMIT <br /> Y SAN JOAOUIN COUNTY ENMRONYENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON PVENUr-STocxTcm CA 95205-(209)466-3420 <br /> NON-REFUNDABLE PERMIT CALL 09 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JoeADDREss 1786 S Mack Tone Rd CrrYl2SP tockton , CA <br /> Farmir��on Rd <br /> CROSS STREET `g-- AP /Y3 030°1 PARCELS D LISEAPPLFCATIDN# p <br /> OWNERNAME Brittalia Ventures IPAPHONE 209-941-4500 N <br /> OWNER ADDRESS`p .C . A3 o x 170 Cn STA.EMp i n d.e n CA 95236 <br /> CONTRACTOR Purviance Drillers , Inc PHONE 209-897-3554 <br /> CONTRACTOR AaoRESS PO Box 64 CriY)STATEMP i n d e n, CA 95236 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTDR ADDRESS C fTISTA7EMP <br /> LICENSE C57 L"l 2 D-09 U Other Nu EER Exyiwno%DATE— <br /> DOMESTIC WELL SA IPIJNG:C General MineralfCaliform Bacteria(439 f)L Dibromochloroprcpane 4392)D Arsenic(4393) w�� <br /> INTENDED UsE 9 DornesticiPrivate O Irrigation/Agricutural C Industrial O VMerOuarity Monitoring ❑Sal Samp,ingfCharactedmfion �1 �•. <br /> Li Waler <br /> ten <br /> Udl,mntRarnOwaar. <br /> INarersywe Name Contact Name ar PSam Number wD <br /> TYPE OF WORK C+New Well ❑Replacement Well G Well AlteratioNMOdiftczbon U Other y `A <br /> ❑MonitoringWell(s) Aofwells 0 SoilBoring(s) 6o1bOfbigs rl Geotechnical aatboaags / 7 0 <br /> 0 Out-0fService Well C OW-0OfWell Renewal D Cmss nection Repair T' d., 7 <br /> C3 New P R Pu R lacement 0 Pum Repair 7,Raise Well Cast SAN <br /> r��A 18 <br /> VLH C <br /> wELLcONSTRUC7foN �CT�I NME CUN�y <br /> DHlling Method o Mud Rotary C Air Rotary ❑Auger C Cable Tool 7 Push Point D Other PqQ <br /> Proposed Well Depth fl Excavation in diame(er J Open BOdom G ravel PacWGravef Size In darn �NT <br /> D Conductor Casing in diameter 1 Conductor Casing Depth ft <br /> W611 Casing Diameter_in ThicknesslGaugelASTM Sched o Steel ❑Plastic Stainless Steel D Other <br /> GrvutSeal Depth_ft D Neat Cement(94 fD bagr:10gef water) D Sand Cern eni sack rn%x17 gal water <br /> C Bentonite(20%solids) D Other <br /> Grout Placement Method-E:Pumped DFree Fab 9 Dther Retardard7Acceler of(name) <br /> PenFSTAL installed By F,Ordier j Pump Contractor 0 Other <br /> O Concrete Pedestal CDimensiorts:Vvidth ft Length RTNck in C Christy Box n Stove Pipe <br /> Puma *Submersible❑Turbnne 0 Other HP Pump Set ft Slanding Wafer Level R <br /> I 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 RUFFS AND REGULATIONS. 1 ALSO CE IFY 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 /> WO ENSATION LAWS. <br /> MINI M HO VANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> stcN Tr,forporate Se re'tary.. 1/29/18 <br /> i <br /> I <br /> l z <br /> G <br /> � <br /> o <br /> m ry M <br /> M co <br /> .00 <br /> y ! v4 <br /> 77— <br /> E.PV R T M E N T U °N Y <br /> Application Accepted 9y Dale�yL / (1 Ale. <br /> Groat Inspection By Date A/PEC1fALW;Z1:itD*k�" <br /> Pump Inspecton By Date I I I Q C WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth M <br /> COMMENTS <br /> PE Sc Received CheckfN Amount Perm(U <br /> C s Into Cash emitted Date Service Request* Involce4l Well ID# <br /> o JAL I1A)P003173 (221 <br /> EFID41-p6 eroins O L,[.�-7� -A WELLRIAAPPERMn <br /> Z-d tZGEZ2860Z `(r `/f out SaalllaQ aoueiAind d0E:90 9L 6Z Lief <br />