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LZWON Wd90 :ti 8l0Z lZ '2ny aulil p;Aiaaa� <br /> r WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY E MONMENTAL HEALIN DEPAKMENT 1868 EAST HAzrLTON AVENurz-STOCKTON CA SSWS (209)468-3420 <br /> NON-REFUNDABLE PERMrT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JoeADORESS 772 S JackTone Pd cry/aPStockton CA 95215 <br /> CROSSSTREET /� APN / PARCEL&ZE LAND USE APPUCATION;* g <br /> OWNER NAME aures La R o r i o INC PHONE209-471-7591 <br /> OWNERADDRESS 155 -N Duncan Rd C11SrATPIZIP Linden CA 05236 <br /> CONniACTOR Purviance Drillers , Inc PHONE 209-887-3554 <br /> CONTRAcToR ADDRESS PC Box 64 CITYISTATEMPL i n d e n ,_ CA 95236 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CrTYISTATPJZ P <br /> s_tceNsE C-57 D C-61 3 D-C9 D Other NULmlaER 377923 E1IPIRATION DATE 7/31/19 <br /> DOMESTICVUELLSAMPUNG:D General Mineral/Coliform Bacteria(4391) Dibrolnochloropropane(4392):!Arsenic(4393) <br /> INTENDED UsE 0 DOmeshrJPdve(e it Irrigation/Agricultural C Industrial D Water Quality Monitoring n Soil SamplingrCharacterization <br /> C Publlc Wats System <br /> Il different from owner Water Systen Nanm Owtad Name Ur Phone Number <br /> TYPE OF WORK C New Well C Replacement Well C Welt Alteration/Modificatim 7 Other <br /> G Monitoring Well(sL 4 of tivells F Soil Borings) Cur Donngs C Geolecrinical >s Dilor nga <br /> D Out-Of-Service Well C Out-Of-Service Well Renewal 0 Crass-Connection Repair <br /> D New Pump C Purnp Replacement XPLxnp Repair 0 Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method D Mud Rotary r,Air Rotary C Auger ❑Cable Tool ;I Push Point 1.1 Other <br /> ,Proposed Well Depth R Excavation in diameter Open Bottom ❑GraverPack/Gavel Sze n diameter <br /> ❑Conductor Casing in diameter t Conductor Casing Depth ft <br /> Well Casing Diameter_in ThidlnessJGaugeIASTM Sched 1:Steel ❑Plastic ❑Stainless Steel Cl Other <br /> Grout Seal Depth ft D Neat Cement(94 lb ba9/5-10 gat%Qfef) 0 Sand Cement sack mixfT gal ureter <br /> D Bentonile(20%solids) D Olher <br /> Grout Placement Method-]Pumped 3 Free Fall C Other C•Retardant f Accelerator(name) <br /> PEDESTAL Installed By Q Drifter 7 Pump Contractor O Other <br /> D Concrete Pedestal C Dimensions:WiMn fl Length it Thick in -I Christy Boz D Stove Pipe <br /> Pump O Submersible&Turbine D Other FP Pump Set fl Slanding Water Level ft <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPUCATiON AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQMN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQLTRED UCENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPUANCE WM-f ALL <br /> WO 6 C PENSATION <br /> MINI iN 24 H NCE NOTICE REQUIRED rFOR INSPECTIONS-PLEASE CALL(209)963.7697 <br /> SrcNED �„yars -n,, 'orporate SecretarDATE <br /> pgyMe <br /> Nr <br /> V1 I <br /> I <br /> UG ?3 ?018 <br /> AQUI <br /> CO <br /> TMENT <br /> EP RTMENT U ^�E 0 y <br /> JAI <br /> AppGcatidn Accepted By Dete v Area Employee ID* <br /> Grout Inspection By Date Q PECIAL WBII Permit <br /> Pump Inspection By G Dale 0 WAIVER Received <br /> Soil Boring Inspection By <br /> Date Constructed Well Depth It <br /> COMMENTS <br /> PE Sc Received Checkfill Amount Date Permit/ involce#i WellID�# <br /> Codes Info Cash eMfted tv- uest* <br /> EHD43-H Wills ("'� T" �+ A•.-;J LCJ 7�� VY�LIPL'kP PER WT <br /> Z'd VZSCZ9960Z 111 cud saalluQ eoueinand d6C:£0 9 6Z End <br />