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WELL/PUMP PERMIT <br /> ..SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER Avg 3m FL-STOCKTON CA 95202 -(209)46"20 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> F JOB ADDUM 14642 E. Eight Mile Rd. ,— Cavan,Stockton, CA 95215 <br /> d <br /> CRDs STREET APN 0?/— dz0^Of PARcex.S[ze �LAND USE APFucATrOr N <br /> O"YRNAME Doris Gogna PHONE "931- 2-993 <br /> OV/NRRADORFM 14642 E. Eight Mile Rd. cnvwSTATEmp Stockton, CA 95215 <br /> CONTRACTOR Purviance Dxillers, Inc. PHONE 209-887-3554 <br /> CONTRACTORADDREss P. O. Box 64 CrrrlSrATLrLIPLinden, CA 9523.6_ <br /> SURK)ONTRAC OR n/a PHONE <br /> SuBComitAcroR AmIlEss CrIYISTATE/LIP <br /> LICENSE 11 C-57 0 C-61 13 M9 13 other NUMBER 377923 EXNRAnON DATE 7/31/0 7 <br /> GEOCRAPRICALINFORMAnoN: Coordinates X Y Township Range Section_ <br /> INP'ENDteD Use O DonlestidPrivate 13 IrrigationtAgricultural O Industrial O Water Quality Monitoring 0 Soil Sarepling/Ghanctcd tion <br /> 0 Public Water Syucm <br /> Irdiff of nam Etat ystem ,me tmt un a <br /> TyPE OF WORK 0 New Well 13 Replacement Well d Well AlteratiordModification 0 Other <br /> 0 Monitoring Wap{s) i!Of Wells 0 Soil Boring(s) xei6oli- aofborkp,Fill, <br /> Q Out-Of-Service Well d Out-Of-Scrvice Well Renewal 0 CrossConnection Rclatir <br /> 0 New Pump 11 Pu R lacertxnl 0 Plump Repair <br /> t�WELL CONBTRUCrION <br /> f Drilling Method 0 Mud Rotary 0 Air Rotary O Auger 0 Cable Too) 0 Push Paint O Other <br /> tF Proposed Well Depth ft Excavation in diameter 0 Open Bottom Cl Gravel Pack 1 Gravel Sia in diamew <br /> ❑Conductor Casing in diameter l Conductor Casing Depth It <br /> Well Casing Diameter_in Thickness/GaugelASTM Schad 13 Steel 0 Plasl, 0 Stainless Steel 0Other 1S <br /> Grout Seal Depth ft 0 Neat Cement(Y4 1b bag 15-10 gal water) 0 Sand Cement pact mix 17 gal Water -� <br /> ❑Bentonitc(20%solids) 0 Manufacturer Spec s/solids % Name 0 Specs on File 0 Specs Submitted N <br /> Grout Placement Method 0 Pumped ❑FmcFall O Other 0 Retardant 1 Accelerator(name) <br /> PLIDWAL Installed By D Driller 0 Pump Contrector ❑ Other m <br /> 0 Concrete Pedestal Dimenrionf:Width it Length ft Thick in 0 Chr)sty Bax 0 Stove Pipe <br /> Flem RSubmersible D Turbine 0 Other HP L_1/2,_ Pump Set 17 0 ft Standing Water Iwai 13 7 ft m <br /> I HEREBY CERTIFY THAT 1 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. 1 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 /> INIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIG i -� TITLE Corporate Secretary DATE 91l_3195_ <br /> �1 <br /> DEPARTMENT USE ONLY <br /> P! Application Accepted By 13 Date Area Employee mo sE <br /> GroutInspection By Date [3 SPECIAL Well Permit <br /> Pump Inspection B ' '' Dau _..12,z 13 WAIVER Received <br /> Fconstructed Well Depth D <br /> jj COMMENTS �f�e�L-et�G �JCe>_��7z� �r/,,f Z'_ic�R�� <br /> PE SC Received « l Amount Date Permit/ Invoice k Well aw <br /> Coda lafe By Cath Remitted Strvlce Request0 <br /> FptDuax-0at WELLPLWPLOW <br /> 1Ri!l00.5 <br /> J <br />