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�1titi "N AH6E :01 8106 ;1111 P;A l ;.�;� <br /> t WELL/PUMP PERMIT ''J �L ur h <br /> SAN JOApuIri COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1866 EAST HAZELTON AVENUE-STocKTON CA 95205 -12()9)d6�' <br /> NON-REFUMA13LE PERhNT / CALL 209 953-7697 FOR INSPECTIONS c EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS ,?4ZS 5- left Lt) CITYl7JP S4OGIc-&1, 4Cq 9sa/2 m <br /> CROSSSTREET 14, leireth_ AP N086q'8'037 PARCELS17E LAND Use APPLICAnoN 9 p <br /> OWNER NAME 0Q 14nO -4 �4 07t��1 �ru&-i PHONE <br /> / n I-- 439aL tN" <br /> OWNER ADDRESS %+25 ). h/" (fln a CRY/STATE1ZP U�7611,(2A 45-L/7-- <br /> COnrnmcrOR Purviance Drillers , Inc PHONE 209—$87-3554 <br /> CONTRALTORADDRESS PO Box 64 CRY/STATE/bpL i n d e n , CA 95236 <br /> SuncONTRACTOR PHONE <br /> SUBCO—ACTOR ADDRESS C17YJST- f <br /> A7TWZIP <br /> LICENSE C-57 LI C-61 U D•09 ❑Othef NUMBER 3 7 / `)2 3 EXPIRATION DATE 7/31 /19 <br /> DoNEsncVVELLSAMPUNc:D General MineraUCDliform Bacteiia(4391)E Dibromochloropropane(4392)-3 Arsenic(4393) <br /> INTENDED USE Ph DamesGrJPnvale C Inigation/Agricultural C Industrial D Water Quality Monitoring n Soil Sampurag/Charactedzation <br /> D Public Water System <br /> Irdirrermt fmm Owner: Water Sy--:em Name CwttaC Nano ar Priam PkmGer <br /> TYPE OF WORK ❑NOW Well C Replacement Well C Wel'AlleralionlModification D Other <br /> C Monitoring Well(s) #Of wells C Soil Boring(s) AOfbo0ngs C Geotechnical a0bo6rIgs <br /> D Out-Of-Service Well C Out-Of-Service Well Renewal C Cross-Connection Repair <br /> New Pump D Pump Replacement D Pump Repair C Raise Well Casing <br /> W7121­1.CONSTRUCTION <br /> Drilling Method n Mud Rotary P.Air Rotary D Auger C Cable Tool ❑Push Point n Other <br /> Proposed Well Depth ft EXCavatlon in diameter D Open Bottom C Gravel PacklGravel Size in diameter <br /> ❑Conductor Casing In diameter / Conductor Casing Depth H <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad D Steel ❑Plastic D Stainless Sleel J Cther <br /> Grout Seal Deplh ft C Neat Cement(94/b baW-1-10 ge/vrafe;l O Sand Cement sack rWxl7 gal water <br /> C Bertonde(20%solids) D Other <br /> Grout Placement Method D Pumped ❑Free Fall O Other C Retardant/Accelerator(name) <br /> PEDESTAL Installed By C Driller ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal CDimensions:Width ft Length it Th!ck in n Christy Box ❑Stave Pipe <br /> PUMP "d SuhmersiblaO Turbine D Other HP Pump Sal fl Standing Water Level fl <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL 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 /> WORKERS COMPENSATION <br /> MINI 1411 24 ANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-76971 <br /> sldN T„f�orporate Secretar&,E /i <br /> - I <br /> 1 z <br /> = <br /> iV I I I ArtIN 0 <br /> z' <br /> —y I\ 'All )'!�Skv ns �OLU <br /> p <br /> tY <br /> s o � <br /> PIS- <br /> I <br /> MLat. <br /> #1 <br /> ENT U O L �r;c <br /> Application Accepted By Area Employee IDU <br /> Grout Inspection By ate ❑ e11 Permit <br /> Pump Inspection By VVI 1:5)~Date ❑ WAIVER Received <br /> Scii Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received CheckW Amount Pennitl <br /> Codes Info B Cash Reinifted Date Service u stU Irrvoice# Well IDU <br /> 4� A <br /> EHD 43-08 6MV1e WELL/"OPPERMI' <br /> /)Z•I <br /> Z'd VL9£L2260Z auk saa11iaQ aautayund ;9012L L L oaQ <br />