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ILLI '0N A V 6 1 :6 L10 lZ 'baa au)i1 paAI D <br /> WELUPUMP PERMIT P z Q <br /> SAN JOAQUIY COurrTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZI�-TON AVENUE-STOCKTON CA 95205-4209)46&.3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> Joe AwREss 9,060 N Clements Rd c,T,mj,idden 95236 m <br /> Messick Rd API 06517020 tt11 a <br /> CROSS STREer PARCEL SIZE 103.7' a USE APPucanoN# <br /> OOwNERNAME Lewallen Land and Cattle o PHONE m <br /> owNER AOOREsS P O B o x 585 CIrY/STATvzIP L i n d e n , CA 95236 <br /> CONFTRA=R Purviance Drillers , Inc PHONE 209-887-3554 <br /> CONTRACTOR ADDRESS P O l3 o x 64 CITYISTATEMP Linden, C a 95236 <br /> SUBCONTRACTOR PF10HE <br /> SUBCONTRACTOR ADORES s CITYISTATEMP <br /> LICENSE EXC-57 O 0.61 D D-09 D Other ,MBER 377923 u,..A,,.DATE 7/31/19 <br /> DOMESTIC WELL.SAMPUNG:❑General MinerallColiform Bacteria(4391)L Dbrnmochlaropropane(4392)J Arsenic(4393) <br /> INTENOEO UsE n nomeSliC/Private R InigationrAgncuttural ❑ Industrial C'/Vater Quality Monitoring O Sail Sampling/Characlerizatian <br /> O Puolic Water System <br /> It tlnerent from Owner Water System Name ConleG Name or Prone Number <br /> FE-CLF WORK 0 New WPJf C Replacement Well O Well Alteration/Modification 0 Other <br /> ❑MONtoring Weks) #CfweMs G Soil Borings) soTbarings D Geotechnical Rorbonngs <br /> Cl Ou:OfSelvice Wet G Out-OF-Service W91 Renewal U Cross-Connection Repair <br /> New Pum ❑Pum R Iacemeni n PUMPRepair D Raise Welr Carie <br /> TRUCT <br /> WELL COnsION <br /> Drilling Method r Mud Rotary G Air Rotary D Auger G Cable Tool D Push Point 0 Other j <br /> Proposed Well Depth 40 2 S7 fl Excavation 2 7- in diameter 4 Open Bottom C Gravel PacIdGravel Size in diameter <br /> D Conductor Casing in diameter r Conductor Casing Depth ft <br /> Well Casing Diameter in Thldcness/Gauge/ASTM Schad Stool 0 Plastic ❑Starless Steel Ci Other <br /> Grout Seal Depth �00 •f" P0NeatCement(941bbag/5-10galwafed ♦Sand Cement 10. 3 sock naxf7gal water <br /> U Bentonite(20%solids) Ll Other <br /> Grout Placement Method ,Pumped 0 Free Fall ❑Other D Retardant/Accelerator(neme) <br /> PEoesTAL Installed 6y IF Driller 0 PUMP Contra Mor U Other <br /> i_ n Concrete Pedestal ODirneneions•Width Fl Length ft Thkk m D Christy Box 'l Stove Prpe <br /> ------------------------- <br /> (PUMP 0 Submersible❑Turbine 0 Other HP Pump Set fl Standng Water Levet ft <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 RULES AND REGULATIONS. t ALSO CERTIFY THAT A RORoANC LICENSE N <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT i AM IN COMPLIANCE WITH ALL <br /> WOR EQUIR <br /> OMPENSATIO $- <br /> Ml UM 2 VANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209 953-7697 <br /> SIGN TiT� Corpor Sectary DATE 1'2/20/17 <br /> ( CEIVE® <br /> EC 21 2017 <br /> v�+�N <br /> ONMENTAL HEALTH <br /> RM1TfSEMACES <br /> pEC 21 <br /> OU1 <br /> SD NE RD�P TyE)11 0E ARTMENT U E NLY <br /> FTM D p <br /> N 4pplicationAmepted By Dale 7/ Areae C / Employee IDA <br /> Grout Inspection By V1 rt, Date [ ❑ PECIAL W811 Permit <br /> Pump Inspection By Date O WAIVER Received <br /> Soil Boring Inspection By Date COn5tructed Wel[Depth ft <br /> COMMENTS <br /> PE SC Recelved CheckW Amount <br /> Codes Into Sh Remitted Service��W est it Invoice A Well 10� <br /> y <br /> EI-!D Cd6 BIO1n8 D/ 7(��{71 <br /> 1`(/ WELL WUMP PERMIT <br /> Z'd tZSUe960Z O(J out 9Je��i�Q e0UeiAand e60:06 Ll 6Zoaa <br />