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HH "N AHLE : 11 8106 '8 'qac ;Wli paAI ;);� <br /> WELUPUMP PERMIT <br /> L <br /> SAN JOACUWCOUNTY ENVIRONMENTALHEALTHDEPARTMENT 1868 EAST HAZELTONAVnvus-SMCKTONCA95208 -(209)4683420 <br /> KION-REFUNDABLE PERMIT CALL. 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JCBADoR13a 2363 Hall Ave crrwzrFStockton 95215 <br /> CROSS STREET 1 a r i p o s aAP 7 U 2--3,DPARc[-1.5�Y�j_` 'LAND IJP APPLICATION o <br /> oWKER NA.41yron Robertson /1 � �'�g� Y Pa{aNc209-406-6086 <br /> OWNER ADDRESS"2 3 6 3 Hall Ave crrylsTATEra�t o c k t o n CA <br /> CoNTRAc,oR Purviance Drillers , Inc 7 P,,cuE 209-887-3554 <br /> C— ACTOR ADDRESS PO Box 64 Cmr1STATEZP L i n d e n, CA 95236 <br /> SUBCONTRACTOR <br /> PHonE <br /> SUBCONTRAOTOR ADDRFSs CrtYISTATEQIP <br /> LICENSE C-W 0 C-61 O D-09 U Other NUMBER F)UVRATION DATE <br /> DOMEsnC WELLSAMPLmG:n General MineraUCaliform Bacteria(4391)L Dbromodtloropropane(4392} Arsenic(4393) <br /> INT--.NOM Us E +DomesGrJPrivale C tnigatior�lAgricultural C.industrial C Water QUalityMonitoring O Soil SamplinglCharaderimbon T <br /> ❑Public Water System �NI <br /> ttdirten'trr Tram owner. Wefar Systecrz Nemo Ca r4oa Name or Phare Kwom 0,I� <br /> TrPEOFWORK 0 New Wel C Replacement Well C Well AlteralioruMccifica6on 0 Other V D <br /> O Monitoring weir(s) 4 o wellS ❑Sa88oring(s) 1114boll- 0 Geotechnical a rummoF�a 1 <br /> n flu#-OFService Well C Ou:OPSe Ace Well Renewal 0 Cross-Connection Repair oe 2018 <br /> (ear Pure. S Pump Replacement r Purnp Repair D Raise Well Casin- S <br /> WELL CON3TRUC Oli11 <br /> Drtlling Method D Mud Rotary C Air Rotary D Auger O Cable Tool C Push Point C Other I-j"ENVIRO ENTANTy <br /> Proposed Well Depth ft Excavation in diameter ❑Open Bottom C Gravel PacklGravef Size in diame� rrt,,+EMT <br /> 0 Conductor Casing in diamefer I Conductor Casing Depth ft <br /> Well Casing Lfameter_in ThichnesdGaugPJASTM Scheel C Steel D Plastic G Stainless Steel 0 Other <br /> Gro4A Seal Depth ft D Neat Cement(94 fa treg#5-10 gel water) :I Sand Cement sock mull gal water <br /> U BerNmile(20%saBds) D Other <br /> Grout PiacementMethod 0Pumped 0Free Fall DOfher �Retardant lAmelerator(name) <br /> PED-E—ST-Al Installed By C Driller 0 Pump ConVaclor ❑ Other <br /> rl Concrete Pedestal uDimensiona:Wldtn f; Length R Thick lin 7 Christy Box 0 Stove PJ pe <br /> PUMP 0 Submersible0 Turbine 0 011ier HP Pump Set h Standi-1 Water Level 1f <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. 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 /> WORKERS COMPENSATION LAWS. <br /> MI UM VANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> sty hTf-orporate <br /> t <br /> I <br /> #I--nL <br /> ` <br /> r , <br /> T <br /> M <br /> tG <br /> 4: 1 W 0 <br /> �r <br /> 420z <br /> CD C <br /> D PARTMENT 7E O Y ' / y OO <br /> APAlicatidn Accepted By Date Area- -(— 7 Employeo IQB <br /> Grout inspection ey r Date 3 SPECIAL W911 Permit <br /> PumA Inspection By Date n i 0 WAIVER Recalved <br /> Sail Boring Inspection BY Date Constructed Wag Depth ft <br /> COMMENTS <br /> PE Sc Received ChecM Amount bate PenntU Invoice# Well IDS{ <br /> C es Info __6 Cash Remitted Service R neat# <br /> 1uu ' ' C- <br /> EEC 43 W'U16 /Y / � t� Ara'-R MPPERMIT <br /> C'd tLSCZ2860Z �J}7/' �J out SJ811!JQ eQUeiAind d6Z:Z6 9L 80 qaj <br />