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H[1 "`N WdWti 8lOZ '8Z A;S ;Wli paAI ;3;� <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONV ENTAL HEALTH DEPARTMENT 1868 EASTHAZELTOM AVENUE-STOCKTON CA 95205- <br /> (2D9)4683d20 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS 11418 E Comstock Rd cm.,aP Stockton , CA a <br /> CROW STREET Beecher Rd APN 08913028 <br /> PARCEL SUE&—AL..USE APPLICATION <br /> 0 <br /> OWNER NAME Britiilia Ventures �f' / � PHONE �` <br /> OWNER ADDRESS • 0 B o x 17 0 ( {i{/• CIN/SFATE/zIP Linden, tl 95236 <br /> CONTRACTOR Purviance Drillers , Inc PHONE 209-887-3554 <br /> CONTRACTOR ADDRESS P0 Box 64 CRVrSTATEp,,L i n d e n , CA 95236 <br /> SUBCONTRACTOR <br /> PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATEIZI➢ <br /> LICE NSE ,C-57 U C-61 O D_C9 0 Other NumeER 377923 EXPIRATION DATE 7 3 1 _19 <br /> DOMESTIC WELL SAMPLING:C General MinerallCQlitorm Bacteria(4391),Dibromoch(oropropane(4392) Arsenic(4393) <br /> INTENDED Usr 0 Domastic/Prfvate InigatioNAgricAluml n Industrial G Water Duality Monitoring D Soil SamplinglCharacleriza-an <br /> 0 Public Water System <br /> e dldarerr imm Owner. vVater Sriiem Horne Centaq Name or phone NuRDer <br /> TYPE OF WORK D New Well C Replacement Well D VLWI Alteration/Modification D other AYIVENT <br /> D Monitoring Well(S) #of wets G Soil Boringo s) d bodop D Geotechnical sorborrngs ECEI <br /> 0 Out•OTSepAce Well O Out-Of-Service Well Renewal 0 Cross-Cmtnection Repair VED <br /> D New Pum Pum C•Replacement Pum Repair. 0 Raise Well Cas <br /> bV rMn <br /> STRUCTION <br /> ethod Q Mud Rotary G AlrRotary D Auger D CableTcol .71 Push Point D Other2018 <br /> WeB Depth ft EzcavaBon in diameter C Open Bottom G Gravel Pack/Gravel Size In di J QU/N <br /> 0 Conductor Casing it diameter / Conductor Casing Depth ft CO <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad ❑Steel n Plastc a Stainless Steel 0 011ier H��T pE MENTAV TY <br /> trout Seal Depth ft D Neat Cement(94 ib bagrS10 gat wafer) D Sand Cement sackmlxl7 gal water ARTM t <br /> D Bentonite(20%solids) J Other <br /> Grout placement Method C Pumped D Free Fall 7 Other 5 Retardant I Accelerator(name) <br /> Eel_TAL Installed By D Driller D Pump Contractor 0 Other <br /> G Concrete Pedestal ODimensions:VUdth A Length; ftThick in ,1 Christy Box D Stove Pipe <br /> FurnP Submersible❑TurbineD Other. HP Pump Setft Standing Water C,evet ft <br /> 1 HEREBY C FY 714AT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WALL BE DONE IN ACCORDANCE WITii 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 COMPUANCE WITH ALL <br /> WO SATION <br /> MI M 2 DANCE NOTJCE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> Sto ,,corporate SecretarLyA,E q '�f <br /> 4� <br /> I <br /> CEIVED <br /> . EP <br /> 8 2018 <br /> i <br /> OWEt"AL HE <br /> RMITfSERVICES TM <br /> PA TMENT USE <br /> Y <br /> Application Accepted By Date -�xa <br /> Area Employee ID# <br /> Grout Inspection By \ Date ❑ SPECIAL Well Permit <br /> Pump Inspection By A �'�� LV3 pt* Data..�n (7.-( (� _ 11 WAIVER Received <br /> Sort Boring Inspection By Date Constructed%Veil Depth g <br /> COMMENTS <br /> PE SC Received CheeloW Amount Permitl <br /> Codes Info h mitted Date S rviee Request# Invoice# Wel 10# <br /> aco as oa souls rjkl- X353 73 <br /> WELL/PUrdP PERRdR <br /> E'd tzscze960Z OUB SAejjiaQ aoueiAind d 67,:90 96 9Z deS <br />