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BD'IN Wd[0:6 8106 '9 'AON ;lull p;AiaD;d <br />WELLIPUMP PERMIT <br />SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTNENT 166e EAST HAZELTON AVENUE- STOCKTON CA 95206 - (209) 468-3420 <br />MUN-KEFUNDABLE VERRMIT <br />GALL 121.191 953-7697 FOR INSPECTIONS EXPIRES 11 YEAR FROMDATE ISSUEI <br />Joe ADDRESS 904.5 <br />!lj ica <br />z CITYIbP P�2 <br />CROSS STREET 6'"7 VOK <br />APN <br />- —'PARCEL <br />SIZE ANO USE APPLICATIONN> <br />�--f <br />/, — <br />OWNER NAME 139. <br />"1T <br />PHONE .26'7— T7f-47Fs— <br />lr <br />OWNER ADDRESS �S/-a G! �T'� <br />ti /La' <br />iJ� �/ <br />CIT17STATFJZIP L /i� A).f. CIS- <br />9'Ss <br />CONTRACTOR Purviance 'Drillers, <br />Inc <br />PHONE 2091-887-3554 <br />CONTRACTOR ADDRESS p" Box 64 <br />i n d e n, A <br />c171.1STATFl C <br />95236 <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE X C-57 L C-61 U 0-09 <br />PHONE <br />Cm7STATE1ZIP <br />NUMBER 377923 EXPIRATION DATE 7/ 31 19 <br />DomEsuc WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) C Dibromochloropropane (4392) J Arsenic (4393) <br />INTENDED USE C DomeslirJPrivate A Irrigation/Agricultural C Industrial D Waler Quality Monitoring ❑ Soil Sampling/Characterization <br />❑ Public Water System J <br />Vdllerem from owner Water System Nana Cortad Name ar Phone Number A <br />TYPE OF WORK D New WeJ D Replacement Well ❑ Well Alleralion/Modificalion 7 Other AD V..I <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring (a) A ofborngs -1 Geoleamical a or toroGs <br />L Out -Or -Service Well U Out -Of -Service Well Renewal 7 Cross -Connection Repair At <br />17;New PLTnD / PcmD Reolacemenl ❑ PUMD Reoair C Rase Well Casino Nnil r <br />Drilling Method C Mud Rotary C Air Rotary 0 Auger 0 Cable Tool 0 Push Point ❑ Other T/V <br />Proposed Weil Depth It Excavation in diameter 0 Open Bottom 0 Gravel Pack/Gravel Size <br />--fir- <br />❑ Conductor Casing in diameter I Conductor Casing Depth ft L <br />Well Casing Diameler _ in Thickness/Gauge7ASTM Schad J Steel L Plastic L Stainless Steel U Other <br />Grout Seal Depth R �j Neat Cement (94 fb bago5-10 pal waters L Sand Cement sack mW7 gal water <br />0 Bentonte (20% solids) 0 Other <br />Grout Placement Method C Pumped ❑ Free Fall 7 Other 0 Retardant / Accelerator (name) <br />PEDESTAL Installed By -I Driller 0 Pump Contractor C Other <br />❑ Concrete Pedestal ❑Dimensions: Width It Length ftThlclr in n Christy Box In Stove Pipe <br />PUMP 0 SUbmersibleIrTurbine 0 Olher HP APO Pump Set W 00 ft Standing Water Level ft <br />I HEREBY CERTFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK HALL 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 />MIfJIM 24 V NCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED i�G! Tl�.orporate Secretar&,, //—/o -/ fl" <br />,jfDEqARTMENT U E ;LY <br />�I A <br />Application Accepted By Oa1e Area -S Employee ID#jiae* <br />Grout Inspection By Dale ❑ SPECIALW@il Permit <br />Pump I nspection By PRQ� ( Dele O WAIVER Received <br />Soil Boring Inspection By Dale Constructed Well Depth it <br />COMMENTS <br />:Ili.��L•7/!/!l�II[t�IG.�G�[UI��Lrll� MAN <br />EHD 4Y0e OnI Me <br />t,,d <br />VZSCZ9960Z <br />�f t 8 r��- 137 Z <br />YELL hll NP PEiMR <br />8 2018 <br />PA �UNN <br />out sielpa eoueinand d0E Z0 9L 90 ^oN <br />