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Qp WELL/PUMP PERMIT I �SANJoAQU1NCOUNrYENVIRONMENTAL HEALTH DEPARTMENT 304E WEBER AVE P'Pa.-STOCKTO14CA95202 -(7U9)4bg-,'i420 NON-REFUNDABLE PERMIT CALL(2091953-7691 FOR INSPECTIONS EXPIRES 11 YEAR FROM DATE ISSUED JOB ADDREN 14642 E- Eight Mile Rd_ _ - Linden Ca 95236 y CROSSMEET Jack tone APN llIiY7l7iPARCELSIZE O L[ OWNER NAM[ _ Doris Gogna PuoRE OWNERADORRW 14642 E. Eight Mile-_RD__.. Crry/WATV7Ar Linde I, Ca 95236 ~ 1 FI CONIRACTott Purviance Drillers— Inc. _ _ _ PHONE - 7- CarrstAcroRADumm P.O.Box 64 CITY113TAT",Linden CA 95236 SUDCONrpACTOR_n/a PHONE SUBCONTRACTOR ADD@E4& CrrvMrATFMP r LIeENss NC-57 0C-61 0D•09 ❑Other NuMsER 377923 EXPIRATIDNoATr 7 03 GEOGRAPWCALINPORMATION: Coordinates X Y Towaship Range Section F, ❑Domestic7Prime ❑lrrigatioolAgricultural 0 Industrial ❑Water Quality Monitoring ❑Soil SamplinWUorttcmiration iO Public Water S))stemFIfAaremmO mOwier. wom bysleal KEM contact FruiW@irot Niciter TYPE OP WORK 13 New Well 17 Replacement Well ❑Well AlterstiorJModificetion ❑Teat Hole ❑othil a MeoitOlin Wella rnberofwens nwnea"'- eam6cofbatnp 4 g {s)__ ❑SoiE Baring(s) ❑deatechnica! C7 Well Destruction a Ou1-OTService Well 11 Out-01-Scrvice We]I Renewal # ❑New Pump ❑PuMR Re lacemeni ❑Pump R it ❑CresaACmrneerion Repair WELL CONSTRUCTION Drilling Melted ❑Mud PMary ❑Air Rotary ❑Auger ❑Cable Tool ❑Puah Point ❑Other Proposed Well Depth ft Excavation in diarleter E3Open Bottom p Gravel Pack/Gravel Size in diameter 13Conductor Coxing in diameser I Conductor Casing Depth R Well Casing Diameter_in TlickneaslGaugrJASTM Schell O Steel 0 Plastic a Stainless Steel ❑Other Grout Seal Depth ft 0 Neat Cement(941h hag/S-10gal v ler) ❑Sand Cement xack mtr 17 gal water ❑Bentonite(20%solids) ❑Manufacturer Spec%solids ! Name_ ❑Specs on Fik O Spam Submitted I Groat Placeineat Merhod O Pumped a Free Fall 0 Other ❑Retardant 1 Accelerator(name) PEDESTAL Installed Br 0 Driller ❑Pump Contractor ❑Other ❑Concrete Pedestal Dimensions- Width R length R Thick in Christy Boz o Saone Pipe FPOMP ❑Submersible 0 Turbine ❑Other HP__ Pump Set 9 Standing Water Level R WELL DESratllC7loN 13tOpen Bottom Cl Gravel Pack 0 Uncascd T ❑Other Well Diameter 4 in Total Depth 70 It DcpthtoWater ft MCasing tobePerrararedrram A to R Sealing Material 1]Neal Cement(911h hag 15-10 ywl water) 1p Sand cement 10.5 rack mix 17 got water ❑Bentonite Pellets ❑Bentonite(2041 solids) ❑Manufacturer Spec%solids Si Name O Spacs on Fik O Speen Subo»pled Placemeal Method ❑Pumped Z Free Fall ❑Other, I 0 Complete with Mushroom Can R below grade_ ❑Complete to Existing Surface Pad 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONX IN ACCORDANCE WITH SAN JIOAQUIN 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 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. INIFVI 1*14 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS SICK TrrLE Corporate Secretary DATE9/16/03 I r U-5 -1 1 Ur- L; r FF-F-IF)d I I I I I I I I IC ew 11 1 I DEPARTMENT USEOFLY ZJ( _ I Application Accepted By .� Oak D L Area Employee IDLY FGrout Inspection By Date 0 SPECIAL Well Permit Pump Inspection By Date © WAIVER Received Destruction Inspm,:tion B Date 5V—Xc3-O%. Can rttct Well Dcptb R FCOMMENTS e 1PESc Amount Check9l Received Data Invdieeif Well 119 Callen into Retntrted as B Service Requestil 2,q 10-? EHD43-024)06 MASTER WATER WELL PERMIT �^i snnovz ,