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��88 'ON�bZZ 0� 8lOZ Ol 'lnr aulil pan190a� <br /> WELUPUMP PERMIT ,V <br /> SAW JOAQUIN CDUNTy ENviRoNMENTAL HEALTm DEPARTMrjdT 1SSS EAST HAZEL AVBJUE-STOCXTw CA 96206-(2Q9)468-We <br /> NON-REFUNDABLE PE5M CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 8740Helen Ln /J` Cfyr/7jp S t o c ktt o n C A - m <br /> CR098 STREET H i 1 d r e t Ti L n APN�8(Pf 705 PatcEL S lel:_LAND USE APPLICATION# o <br /> OWNER L J ^_ PFiOIE Pm' <br /> owNER AOORESS 8 7 4 6 Helen Ln C TY/STATFJZIP_Stockton C A 9 5 21 Q2L <br /> CONTRACTOR Purviance Drillers , Inc PFIONE 209-887-3554 <br /> CONTRACTOR AonREs3 PO Box 64 c,,sTATFmpL i n d e n , C A 95236 <br /> SUBCONTRAC70R PHONE <br /> SUBCONTRACTOR AvoRPaa CITrISTATEILP <br /> LICENSE C-57 U C-61 ❑D-09 0 Omer NuMeEt 3 7 7 9 2 3 EMMATwN DATE 7/31/19 <br /> Dow,Esnc WELL SAMPLING:D General Mineral/Coliform Bacteria(4391)L Dibromochloropropene(4392)=Arsenic(4393) <br /> INTENDED USE Dornesth/Privale G InigationlAgriculairai G Industrial 11 Water Quality Moritoring 0 Soil Samp6ng/Charactenzation <br /> ❑Public Water System ��� <br /> IrClSrne <br /> el from Owner. Water System P <br /> Name Contact Nam- Number IV <br /> Ty <br /> rOPWORK 0 Iry Well O Replacement Well G Well Alterallon/Modification 0 Other <br /> A orborngs r A or borings <br /> G Monitoring Wel(s) #of wells ❑Sol!t3oring(s) Geotechnical J <br /> 0 Out-OfSrJvice Wen 0 Out-01-Service,Well Renewal J Cross-Connection Repair , <br /> 0 New Pum Pump Replacement GPump Repair D Raise Well Casing 0 <br /> 18 <br /> WELL CONSTRUCTIONA <br /> Drilling Method 0 tAud Rotary 0 Air Rotary 0 Auger 0 Cable Toot 0 Push Paint G Other FNV� /N CDUN <br /> Proposed Well Depth it Excavation In diameter 0 Open Bottom i_Gravel PaddGcavel Size in di gR�rAt n' <br /> 0 Conductor Casing in diameter r Conductor Casing Depth t jue <br /> Well Casing Diameter_to Thidmess/Gauge/ASTM Sched D Steel ❑Plastic C&rainless Sleet 0 Other <br /> GroutSeal Depth R --Neat Cement(941bbaySlOgalwafer) USand Cement sack rrlrxf7gal water <br /> 0 Benlonile(20%solids) C Other <br /> Grout Placement Method 0 Pumped 0 Free Fab 0 Other 0 Retardant/Accelerator(rame) <br /> PEDE3TAL Installed By 0 Driller G Pump Cantraclor ❑ Other <br /> 0 Concrete Pedestal DDimensions:Width ft Length It Thick in it Christy Box n Stov <br /> PUNP ubmersihle0 Turbine G Other HP f Puny Set H Standing Water Level R <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION Anb THAT THE WORK WILL BE DONE IN ACCORDANCE WITI4 SAN <br /> JOAQUIN COUNTY ORDINANCES.STATE LAWS, AND RULES AND REGULATIONS. 1 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 /> WO PENSATION <br /> NIMH f'1M 6 R V NCE NOTICE'REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SICNED T, orporate Secretary, 17_g—/9 <br /> I <br /> M <br /> z <br /> Mo C <br /> i �m <br /> MC= rte. <br /> 9j L —M " 00 M <br /> 1 ; r <br /> i <br /> I <br /> EP RTMENT USE PINLY / / <br /> Application Accepted By Date �Z Area Employee ID# V 1/(� <br /> Grout Inspection By Date`j7����.�, i7 SPECIAL Well POITTIit <br /> Pump Inspecbon By Date I t Ll 1 Rl Cl WAIVER Received <br /> Soil Boring Inspeclfon By Da Constructed Well De ft <br /> COMMENTS �CLwA )V,% aLaU or7 AA) ('"4-V ca <br /> PE SC Received Checlow AmountPermw <br /> Codes Into Cash emitted Date Service R uest# nvoice# Well IDf1 <br /> 7 <br /> LA3PQb <br /> EHD43-06 BNtne nw T� — �� ^ WEL IPUMP PERMIT L <br /> £'d �ZGU2960Z oUI saelllaa eouel/Und e00:0L 9l 06 Inf <br />