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1 , <br /> StiH '°N A'i BIR '0[ 'Inr awil paAI ;D;� <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIU COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZFLTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMff CALL 209 953-7697 FORMSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JDs ADDRESS 8398 N J a c k T o n e R d C,Tylzjp j m <br /> n D <br /> CROSS STREET �( r /�11 ,C.� APN �6 v PARCELSIZE�_t-AHD USE APPLICATION IV <br /> OWNER NAMEArlene Anderson Tr PHDNE209-639-5662 <br /> OWNER ADDRESS 16750. Pearl Ranch Rd CITv/STATE/ZP Fort RraWj CA 95437 <br /> CONTRACTOR Purviance Drillers , Inc PHONE 209-887-3554 <br /> CQNTP.AL'TOR ADDRESS <br /> PO Box 64 cn,,,,ATE/z,PLinden , CA 95236 <br /> SUBCONTRACTOR PHONE <br /> SuacoNTRACTOR ADDRESS CITYISTATEMP <br /> LICENSE X C-57 U C-61 D 1),09 r-other NUMSER 377923 EXPiRATIDN DATE 7/3 1/ 1 9 <br /> DOMESTIC WELL SAMPLING::7 General MlnerallColi`orm Bacteria(4391)f-Dibromochloropropane(4392)-a Arsenic(4393) YAf <br /> D Sy <br /> rNTENDED USE 7 DomesticlPrivate O Inigatien/Agricult ral 0 Industrial D WatarQuality Monitoring ❑Soil Sampling/Characterizabon — it ♦AA <br /> Public Water stem D <br /> IfdIFtrent Sam Owner. Wader Syefem Name Catadl Name.,Ph..Number it <br /> TYPE OF WORK D New WeJI =Replacement Well 0 Well ANeratioNModTication ?Other UL <br /> 122018 <br /> r.1 Monctoring Wells) #o!yells ❑Soil BOring(S) o of bon.,gs F Geotechnical #of boltppf,, <br /> D Out-Of-Service VNwl 0 Out-Of-Service Well Renewal D Cross-Connection Repair `'N�I'��A <br /> ❑New Pum p Pum Replacement n Pum Repair a Raise Well CasingFNV/ Q /N CoI'J <br /> WE -CONSTRUCTION y 0 ENTq N� <br /> Drilling Method 0 Mud Rotary 7 Air Rotary 0 Auger ❑Cable Tool CI PUStI Point 0 Other C <br /> Proposed Well Depth ft Excavation in diameter i.7 Open Bottom :Gravel Pack/Gravel Size to diameter RTM�Nr <br /> ❑Conductor Casing in diameter / Conductor Casing Depth 1l <br /> Well Casing Dianneter_in ThicknesslGauge/ASTM Schad D Steel 0 Plastic C Stainless Steel C3Other <br /> Grout Seal Depth H -3 Neat Cement(94/b bagrSlO gal watery Lf Sand Cement sack"xn gal veater <br /> ❑Bentonite(20%solids) ❑Other <br /> Grout Placement Method =Pumped ❑Free Fall :)Other ❑Retardant/Accelerator(name) <br /> P£DE9TAL Installed By 0 Driller 0 Pump Contin ❑ Other <br /> 0 Concrete Pedestal❑Dirnensiom:Width H Length ft Thick in F1 Christy Box 0 Stove Pipe <br /> PUMP 0 Submersible❑Turbine D Other HP pump S ft Standing Water level ft <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION ANO THAT 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 /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATI <br /> SIGN' MINIAN.111111i A ANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> , T,Ttiorporate Secretarry rf-Q-iS <br /> M <br /> z <br /> S 7 r-- <br /> r�� a <br /> M <br /> <i <br /> N <br /> 65 S _ <br /> 00 <br /> b <br /> I i I 2 <br /> I <br /> EP RTMENT SE NQLY <br /> Application Accepted By r I Date j7i o Area Employee ID#� <br /> Grout Inspection By Date O 1'>ECIAL Well Permit <br /> Pump Inspection By Date .WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth R <br /> COMMENTS <br /> PE SC Received CheckM Amount Date Permit/ Invoiced Well IDH <br /> C s Info sh Remitted Service Req east <br /> P0 Q <br /> LSO X3-06 aRt/le � W9.L RUMP PERMIT <br /> 9'd VZS' LZ 860Z OUI SlelliaQ aouelAjnd e60:0I, 81, 1 Inf <br />