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00R '0N W E : l L[06 '66 '0;4 broil paAiaOa� <br /> WELL.PUMP PERMIT r ✓ 0 <br /> SAN JOAC UIN COUNTY EWIRONMENTAL HEALTH DEPARTMENT 1a66EASTH-LTONAVE7vuE-STOCRTONCA95206-(208)4683420 <br /> NON- FUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> 1.103 ADGR=SS 10624 K Hwy. 88 cmaP Stockton Ca Q5212 m <br /> C ROS a ST IEET E i g h t Mile P d APN 0 6 312 018 PARCELS I,%A-1"USE APPUCATION <br /> 41 <br /> OWN----'-Emily K & Pete G Katzakian Famil Tr , 209-479-3865 <br /> t, It tEXk POR-ox 788 W P CA 952 <br /> OWNER DRESS CfTY1STATEM, <br /> CONTRACIDR PurviancC Drillers , Inc PHONE 209-887-3554 <br /> CONTTtAC R ADDmms P O B o x 64 CITY/STATE21P Linden,C a 95236 <br /> SUBCONTRACTOR PHONE <br /> SUBCONACTOR ADDRESS CITYISTATEI25P <br /> LrcENSE LXC-57 D C-61 u D-09 D Other NUNIBER 377923 Ex -....,E 7/31/19 <br /> DomEs,nc WELLSANaLnG:L7 General KnerailColifolm Bacteria(4391)C Dibromochloropropane(4392)'Arsenic(4393) <br /> IrrrE7�DEO SE D DomesGclPdvate I Irrigation/Agricultural ❑IndustrialWaterOcali..y Monitoring O Soil SampfingrCheracterization <br /> ❑Public Water System <br /> tf41RErerrfm.0wner. Walersystem Name COnredNome ofPttoneNumber <br /> 7VPEOF RK ,M.New Well 0 Replacement Well ❑Well AlteralionlModifiratlon J Other <br /> D Monitoring Well(s) #of wells 0 Soil Borings) Rol Den"P G Geotechnical R 0bonog, <br /> D put-Of-Service Well D Cul-OrService Well Renewal 0 Cross-Connection Repair <br /> ri New Pumo n Purnp Replacement G Pum Repair 0 Raise Well Casino <br /> WELLCO TRUCnoN <br /> DrillinoMo4had k Mud Rotary D Air Rotary ❑Auger Cable I ❑ Push Paint ❑ Other <br /> Proposed all Depth/ Excavaiian 'in di ��eF 8 Open Bottom D Gravel r acJ<!G oval Sizc in diameter <br /> O Conductor Casirp in diameter f Conductor Casing Depth ft <br /> Well Casing Diamele J jPThk*ness/Gauge/ASTM Schad .IFS- G Steel 0 Plastic 0 Stainless Steel U Other <br /> Grout al D —ft.41(0 Neat Cement(94 it,ba96-10 gal water) M Sand Cement l V. 3 Sack mtvf7 gal water <br /> ntonite(20% <br /> U Besolids) D Other <br /> Grout Plac amentMethod 4 Pumped D Free fall ❑Other U Retardant/Acceleralor(name) _ <br /> PEDESTAL Installed By a Driller D Pump Contractor 7 Other <br /> Concrete Pedestal ODimansioos:Wdlh It Length ft Thick in D Christy Box O Stove Pipe <br /> P P =Submta siblea Turbine _Other HP Pump Set ft Standing Water Level S <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK 1NILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN OUNTY 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 /> WO4KEOMPS ATION I.A <br /> IMU 4 HO Q VA CSE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)963.7697 <br /> ✓���`` TM.E C o r p o r Sectary DATE 12/20/17 qY <br /> FCE ENT <br /> l VFp <br /> 4:A1pp2D18 <br /> AQU/N COIJ <br /> ifIfr �EpgR MN7Y <br /> m <br /> 2 <br /> �o M <br /> r� <br /> �n 0 <br /> rh <br /> �z �'' <br /> m _ <br /> y tG <br /> - <br /> __ m = o <br /> D_ PARTMENT SE 1lO LY `/���/,�_M -'Z3 M <br /> Applic ion Accepted By Data fi L Area �IEC.IL <br /> Employee IDO"Al <br /> Gr ut inspection By / Data �' ❑ Well Permit DO" <br /> / <br /> P pinspedonBy Date WAIVER Received <br /> Soil Bor Ig I eUlon B Date Co stru ted Well Depth R <br /> COMMENT Z 1., 51� `1��t- KULj 7c- <br /> PE C I Received eck4f Amount Permit/ Irnolee# WeIIID# <br /> Codes Info Cash Remitted Service Ra uest# <br /> EHD 43-0G 8q/10 ' ffO/ <br /> �'rrri WFLL/PUStP PERMIT <br /> £-d VLS£L9260Z oul saellla4 eoueiAand eSZ:L L L L 6Z oea <br />