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- I L00�"N AVE :01 60 'Ol 'A'pW IWI J paAl ;);y D V WELLlPUMP PERMIT RUED I, SAN JOAQUIN COUNTY ENVIRONMENTAL.HEALTH DEPARTMENT 1868 EAST HAZELTCN AVENUE-STOCKTON GA 95205 92091 48 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADORE�763 S Hewitt Rd c,4rinden CA 95236 CROSS STREE,Copperopolis R�C1nPN/23-360-'lf'1 PARCELS-Z d5 DUSEAPPLICATION* g rnYNERNAMEBWC Weststeyn LP PHDN�09-404-9100 OwNERADDi1763 S hewitt Rd CI1Y/sTATT0PLinden CA 95236 CONTRACTOR Purviance Drillers , Inc PHDRE 209-887-3554 CONTRACTOR ADDRESS P O B o x 64 CITY/STATElZ P Linden ,C a 95236 _ SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS Cr ryIS fATFJDP LICENSE EXC 67 C"It L D-09 L Other NUMBER 377923 E.PIRATION DATE 7/31 /19 Dom nc WELL SAMPLING.-C General Mineral/CDftan Bacteria(4391),'- DibromocNoropropane(4392):1 Arsenic(4393) I NTENDE13 USE C CamestidPdvate If ItTgation/Agricultural C Industrial ❑Water Quality Monitoring ❑Sof Sampling/Cherdctenzation 4` C Public WalerSystem it allfsrem from Owner. Water Sy9em Nerve C.r"d Name ar Phone Namber TYPE OF WORK C New Well C Replacement Well ❑Well AlleratiorJMDdihcation ❑Other CMonitoring Well(s) #of wells n Soit9oring(s) saroorirgs C Geotechnical 7lorhonngs N/q� n Out-01Service Well C Out-Of-Service Well Renewal ❑Crass Connection Repair ❑New PUMP ❑Pimp Replacement W Pump Re air 0 Raise Well Casio WELL CCPJSTRUCnOW DrillIng Method 0 Mud Rotary ❑Aa Rotary n Auger ❑Cable Tool n Push Point ❑ Other FNV�R010 Q /NCDV Proposed Well Depth ft E)cavation in diameter 7 Open Bottom ❑Gravel Pa*Gravel Size in m � RTTA� D Conductor Casing in diameter 1 Conductor Casing Depth It MENT Well Casing Diameter_in Thidmess/GaugeJASTM Sehed ❑Steel L Plastic L Stainless Steel ❑Other Grout Seal Depth It ❑Neal Cement(94 Ib beyr5 toga/water) C Send Cement sack mfi17 ga:water D Bentonite(20%soids) ❑Other GroutPlacemenlMethod ❑Pumped C Free Fall ❑Other C Retardant/Accelerator(name) PEDESTAL Installed By Cl Oriller ❑PUMP ContradOr n Other ❑Concrete Pedestal❑Dlmanslons,Width ft Length ft Thick in ❑Christy Box 7 Stove Pipe PUMP C Submersitle Turbine D Other HP Pump Se ft Standing Water Level ft 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MI MUM2 ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209),953-7697 src � T Corpor Sectary DAt� ) I 41 I 1 I PA TNIENT UIE YINLY Application Accepted By Cate Area Employee ID*JO-F-�* Grout Inspection By �,,n�, Date O PECIAL WAIT Permit t� Pump Inspection By t 11 Y 9 IsooO tJ io ,e nS(2�i_=�l -1 WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS PE SC Received Cheew Amount Date Petmitl Imrolce19 WelllD4 Coiles Into BY, jCash hied Request 4 S i EHD43-as a.Mf,e /L �jwsumuuPPenµr, b d VL9'�L8860Z 7Q out Sa811i.IQ 001-11=in.lnd e�-V:60 60AeN