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90WIN AVD:k LM •8 -ASA Dahl paAI ;3;� <br /> ` WELUPUMP PERMIT <br /> SADA JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1869 EASTHAZ1ELTON AVENUE-S-rK-N CA 95205-(209)466.3420 <br /> NON-REFUNDABLE PERMIT CALL 209)963-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> JoaRooREss 3265 N . Cherryland AveCITYrbP Stockton , CA 95215 ' <br /> CRDs SIRE Water o R 1�7- ' <br /> APN f o�ZZ PAACILSIZE- BLAND USE APPI.IC0.TION p <br /> OWNER NAM1:E Pro Tech PHONE 209-639-6390 <br /> IC WNER AC)oRiEss 11490 N Alpine Rd��n �/ C.I$TAIE11P, Stockton, CA 95212 <br /> CONTRACTOR Purviance Drillers, Inc. PRONE Z09-887-3554 <br /> CONTRACTOR ADDRESS P- O. 'ROX 6 dGinrlen, Cil 9—52-3 <br /> CITVISTATEMP <br /> SUBCONTRACTOR <br /> PHONE <br /> SUBCONTRACTOR ADDRESS CITY1$TATEIZji <br /> LICENSE G-57 G-61 D-09 _Other Nu+eam 377923 EI,pIRATION DATE_7/31 /1— <br /> /31 /1 7 <br /> GEOCRAPHICALINFORMA"j: Coordinates X Y Taavrlshi <br /> 1NTT3JOEO UsE p Range Section <br /> iomsucJPrtvate •InigaUoNA-9dCullural L Industrial -Uvaler Quality moniioring -Soil SamptinglCharacterzatian I <br /> Public Water System <br /> Ird(Mrant from LValw em vno <br /> n a arro ar ,ono rmioer <br /> TY*EOF'NORK _Ne,VVell Rep4acementVVe9 t:Well AlteratloNMOdificalion L;Other <br /> M0rfdOdngWell(S) 901'Wells ,-:SdIl3orlig(s) 9010adnas - Gectechnicat =ortwdpgs <br /> ce Wel; -Oral-CII-Service'Well Renewal -Cross-COnnecfion Repai; <br /> 20:111.10= Z PUMP Re tacement is Pump Repair =Raise Well Cas r <br /> WEL C--TRtICnoN <br /> tfDrifting Method Mud Ralary _Ai;Rotary ..Auger Cable Tool --Push Pcint L Other <br /> Protwsed Wel] Depth 9 Excavailon in diameter =Open Bottom Gravel PaduGtavel Size fn draMVer <br /> Conductor Casing In diameter / CandtIctor Casing DeDlh ft <br /> Neil Casing Diameter_in 7t1ldmess1Gauge/ASTM SchadSleet ,�Plaztic <br /> Grout Seal Depth = Stainless Steel .�Other <br /> p R =Neat Cement(9416 09540ga!wafer) -Sand Cement sack rmx1T gal t rater <br /> _6ent0nite(2(7Sb MOOS) f Other <br /> Grout Placement Method -Pumped `Free Fall =Otber „Retardant/Acoeleralor(name) <br /> LPEDESML Installed By =Dnller -Pump Contractorncre _ Other <br /> L <br /> COMM Pedestal IN <br /> Dimensions d91 R Length r Th tlt in Chnsry Ba>< Stave Pipe <br /> a P Submersiblef-;Turbine ..Other HID -7 Pump Set ft Blanding Water Level R <br /> I HEREBY CF.3tTIFY 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- I ALSO <br /> CERTIFY THAT MY REQUIRED LICENSE IS <br /> CUR D ACi1uE W E CAUFORWA CONTRACTORS STATE LICENSE BOARD AND THAT AM W COMPUANCE WITH ALL <br /> ,V " CO ENSATI <br /> IN M 2 ANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> $+ ^/ TITLE Corporate Secretly 5/8/17 <br /> rM <br /> pAY Q <br /> lee30 I 1 <br /> SP�►E�RpNME TMEN� <br /> P RT4IENT U F NLY <br /> LTH DQE'pp icalion Accepted ev Date Area <br /> Grout InspectIon ByDate I Em70yee I�� <br /> -ClPLVVeil Permit <br /> Pump Inspect on By As �4t�I►�,rr n Dale_7 �o f� 7 WAIVER ReCelved <br /> Safi Eorina inspectlan By Date Constructed YYelf Depth <br /> COMMENTS K <br /> PE SC Received Cheaw Amount Permit/ <br /> 1 Codes Info B Cast, Remitted Date Service Request# Invoice» Well IDOA <br /> ! A007-7 <br /> c7 <br /> 3 <br /> -0, <br /> -nnT? :reLL A-U:.a: <br /> ER:d.T <br /> £•d VZSSL2960Z oul siallp(]eouei/und d££:90 7,0 90024 <br />