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t <br /> StiOS '�N PH : l l 6M '0Z 'ApA IWIJ panI ;�;� <br /> WELL/PUMP PERMIT <br /> SAN JOAOUtN COUNN ENVIRONMENTAL HEALTH DEPARTmetsy lase EAsT HA213TON AVENUE-STocKTON CA 95205-(209)4603420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joe AoaR s oms oc Rd DITM,�,inden Ca 95236 <br /> Tully <br /> CROSS STREET <br /> RdAPN / �ZZ PARCELS¢E��USEAPPLICATIONx S <br /> OWNER NAMEPHw209-482-0348 H <br /> ONMERAODRESS E Eight Mile Rd/yo— <br /> rpTE0pLinden CA 95236 <br /> CONTRACTOR Purviancd Drillers , Inc PHONE 209-887-3554 <br /> CONTRACTOR ADDRESS P O B o x 64 QTY/STATE/ZIP Linden,C a 95236 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR Aowiis5 GIrr1STA7VZIP <br /> LLcENSE LXGS7 D G61 ❑D-09 U Other Nu.m srm 377923 ExpIRATION DATE 7/3 1/19 <br /> DOMESTIC WELL SAMPLING, General Mineral/Coliform Bacteria(4391)C Dibramochloropropane(4392)!1 Arsenic(4393) A <br /> INTE'R1E0 USE D DomestcrPrivate !Imgetlon/Agricultural ❑Industrial D Water Quality Monitoring O Sol Sampling/Characterization <br /> D Public Water System �q <br /> IrdiOereM hon Owner. WA-er SymName Carrta¢Nameor Phone Number ``! iFwN� <br /> TWE OF WORK D New Well 0 Replacement 6Vell :1 Well NteraliorUMOdfication r Other Mq y 2 F� <br /> ❑Monitoring Wells) #of wells El Sail Boring(s) aorboriaps 0 Geotechnical yon feel gs <br /> O OUt-Of-Servlce Well L Out-OfSafuioe Well Renewal ❑Crass-Connecioon Repair <br /> n N.?um Plan Replacement D Pum Repair U Raise Well <br /> Cesin S ✓�qQ � 20,0 <br /> W ELLCONSTRUCTION H N�iRo V/H co <br /> Drilling Method 7 Mud Rotary C Air Rotary 7 Auger 0 Cable Tool ❑Push Paint ❑ Other <br /> Proposed Well Depth ft Excavation in diameter 0 Open Bottom C Gravel PaWGravel Size in diameter T h 'p <br /> DConductorCasin9 in diameter / Conductor Casing Depth It EHr <br /> Well Casing Diameter_in ThicImss/Gauge/ASTM Sehed _S1eel U Plastic ]SkinlessSteel D Oiher <br /> Grout Seal Depth ft D Neal Cement(941bbag'5.10 galwatei) 0 Send Cement sack mlx/7geIwater <br /> ElBentonite(2096 solids) FJ Other <br /> Grout Placement Method 0 Pumped D Free Fall 7 Other G Retardant I Accelerator(name) <br /> PEDESTAL Installed By 0 Driller ❑Pump Contractor 0 Other <br /> [IConcrete Pedestal❑Dimensions:WiQh ft Length ftThlck in 0 Christy Box ❑Stove Plpe <br /> PUMP U SubmerslUe!Turbine ❑01her HP -f Pump Set ft Standing Water Level ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SANLS <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 /> M1N€ M 24 A ANCE NOTICE REQU€RED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> sLDNEtO - - � Corpor Sectary DATE <br /> I I <br /> i <br /> I <br /> I Ll <br /> A MENT USjE OILY i7'�I - ' <br /> Application Accepted By Dale y Area *SPECIALWell <br /> Employee ID#^ I%/V/"f't� <br /> Grout Inspection By Dale t ❑ Permit <br /> Pump Inspection ByWKI Dale 0� tO\ O WAIVER Received <br /> Soil Boring Inspection By Date Constructed W all Depth ft <br /> COMMENTS <br /> PE SC Received Clteclaw Am Dunt Date Permit/ Invoice# Well IM <br /> gets Into A LqemlaW Service_Request# <br /> - WfOOG <br /> ,39 <br /> FHD 4 3-a4 d,0111e _ m /0(L6� WELL RU1JP PERMZ <br /> Z'd tZSEZ8960Z ( OU1 SAejjiJQ eDUelAind eft':06 6� OZ AeN <br />