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X811 OVMVSO:E-9lN`6 'daS—awil PaAJaD;� <br /> e T-1,1001A Sean <br /> WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH OEPARTAIEW 1868 EAST HAZELTON AvENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(20D 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATEISSuFM <br /> Jos AODREss Shelton RD cmrZIPLindeni CA 95236 Im <br /> 093-31-004 't < ' <br /> CRo3,STREET r l��G�V e I 1 V RD _—APN PAFtCEL�yy]J—LAHD USE APPLICATION# a <br /> m <br /> OWNER NAMEAG West– Olive to R_anrh _. PHDNE209-887-3554 u <br /> OWNER ADDRESS P -0. 13 o x 739 ctT,-,sTATF ztP L i n d e n(� CA 95916 <br /> CONTRACTOR Purviance Drillers, Inc. PHONE 2109-887T-3554 <br /> CONTRACTOR ADDRESS `p• O• "Box 64 CITYISTATFRIP L ir>d en, CA q 5 23 <br /> SUBCONTRACTOR _ PHONE I <br /> SUBCONTRACTOR ADDRESS CRY/STATEMP <br /> LICENSE U C-57 U C-61 LI D-09 U Other NUMBER 377923 FJtPIRAT10iY DATE <br /> 7/31 /17 <br /> GEOGRAPHICAL INFORMATION: CoordinateSX Y Township_ Range Section_ <br /> INTENDED USE ^DOrnestICJPrivats Winigallon/Agriculural ❑Industrial ❑Water Quality Monitoring Ll Soil Sampling Characterization <br /> :Public Water System <br /> I`eMemnc nom Owner a er ya ern me n a —w — .msec <br /> TYPE OF WORK L!New Well L Replacement Well Ll Well Alteratlon/Modfication Other I <br /> fl,MonitoringWells #of wets nSo9Borin s #olbodngs oorbonnys <br /> (1 9O '-Gedechnital <br /> Out-Of-Service Well rl Out-OfSemice Welt Renewal n Cross-Connection Repair <br /> At m <br /> New Pump E Pup Replacement D Pump Repair C Raise Well Casing l <br /> WELL CONSTRUCTION <br /> (Drilling Method L Mud Rotary I-Air Rotary .. Auger L Cable Tool -i Push Paint u Other <br /> Proposed Well Depth ft Excavation in diameter 2 Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> J Conductor Casing in diameter f Conductor Casing Depth R <br /> Wel;Casing Diameter_in Thickness/Gauge/ASTM SchedSteel ❑Plastic = Starless Steel Other <br /> Grout Seal Depth ft _1 Neat Cement(941b bag/5-10gaf water) ^..Sand Cement sack rr=7 gal aster <br /> -1 Sentanite(20%sods) T Other <br /> Grout Placement Method C Pumped -Free Fall C Other C RetardantI Accelerator(name) <br /> P6D s7A Installed By Driller 7 Pump Contrartor In Other <br /> UConcrete,Pedestal-Dimensions:Width ft Length ftThck in UChristy Box uStovePlpe <br /> PUI.1P to Submersible&Turbine I.!Other HP PLmp Set ft Standing Water Level ft <br /> I HEREBY CERTIFY THAT l HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN I <br /> JOAQUIN COUNTY ORDINANCES.STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT, MY REQUIRED LICENSE 1S i <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM]IN COMPLIANCE WITH ALL <br /> •\ <br /> I-VORKSR54OMPENSATION LAWS p <br /> MIN �UM24 �VANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)OS 7697 <br /> sIG TITLE Corporate Secretly <br /> e3 ai <br /> f <br /> ILP <br /> REIM <br /> I i I <br /> I 1 <br /> ENVIRONMEN i <br /> '9 —ET11 <br /> PERMIT/SE <br /> PAYME _ <br /> RECEIvE. RTmENT U E N L Y <br /> SEP 9 20�Appl'Ication Accepted 0 _:JLDate Area Employee ID#.J55ZP- a 0 <br /> NTut( GroInspection By Date ❑ SPECIAL Weil Perrrtit <br /> ,JrvO1RONM1 Pump Inspection 8y Oate�pS�� ❑ WAIVEA Received <br /> r�ALTH DEMiI Baring i vspecGon By _ —,_ 03le Constructed Well Depth_ <br /> COMMENTS <br /> PE SC Received Check* Amount Pennid <br /> Codes Info B Cash Remitted Date Serv;ce R nest# Invoice# Well IDA <br /> jk SP-66 l W 25 <br /> I <br /> EHDilmd y �p, . jt 7OQ I WELL PU7.eP PERM <br /> NJm12 <br /> �'d t7L9£L9960Z oul sJalliaQ eouelnand d60:90 ZO 60 ad'd <br />