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W ELL / V U 1V1Y 1"L+'1cV111 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH Dr TMENT 304 E WEBER AA..3"FL-STOCKTON CA 95202 - (209)46$-3420 NON-REFUNDARLE PERMIT '— :ALL 209 953-7697 FOR INSPECTIOP l 1RES 1 YEAR FROM DATE ISSUED JOB ADDRESS 8899 N CITYIZIP' (WatPri cio)Stockton ern .- . D - 030 - �4- Comstock CROSS STREET PARCEL SI"LE r� OWNER NAME Richard Maragliano PIIONE s- OWNER ADDRESS 2477 N. Alpine Rd. CITYISTATEIZIP Stockton, CA CONTRACTOR Purviance Drillers, Inc .. PI[ONE2-0-9-887-3554 CONTRACTOR ADDRESS P. 0. Box 64 CITY/STATE/ZIP Linden,Ca 95236 -S t SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITYISTATE/ZIP LICENSE IXC-57 ❑C-61 ❑D-09 ❑Other NUMBER 377923 ExriRAT1oN DATE 7/03/03 GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section j 1 INTENDED USE IXDOmcstic/Private Q lrrigadotnlAgricultuml ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Charactcrizatioa �[ t ❑Public Water System % IfDifferentfromOwner: 1 ater Sysicin Naine Coritact Narneor ' ooe Nutiibcr TYPE Or WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other ©Monitoring Well(s) number of wells ❑Soil Boring(s) number of borings ❑Geotechnical number of horings 1X Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal p New Pump ❑Pump Replacement ❑Pume Repair ❑Cross-Connection Repair WELL CONSTRUCTION , Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point Cl Other Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter �^ El Conductor Casing in diameter / Conductor Casing Depth 11 S Well Casing Diameter in Thickness/GaugelASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other Grout Seal Depth ft ❑Neat Cement(941h hut;/5-10 bol water) CI Sand Cement surk urix 17 gal water ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Narne ❑Spa;S on(rile ❑Specs Submitted Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By ❑Driller ❑Pump Contractor fD Other ❑Concrete Pedestal Dimensions: Width It Length ft Thick in ❑Christy Box ❑Stove Pipe PUMP 0 Submersible ❑Turbine ❑Other HP Pump Set' ft Standing Water Level 11 "Y WELL DESTRUCTION N Open Bottom ❑Gravel Pack ❑Uncased ❑Other h; Well Diameter 1 () _in Total Depth 1 S it Depth to Water R ❑Casing to be Perforated from ft to It Scaling Material ❑Neat Cement(941h hug1540gal wafer) IN Sand Cement 10 , 5 suck rnia/7 gal water ❑Bentonite Pellets a ❑Bentonite(20%solids) Q Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Placement Method D Pumped ❑Free Fall ❑Other ❑Complete with Mushroom Cap ft below grade ❑Complete to Existing Surface Pad I 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 t CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENS N LAWS. 6. I MUM, 4 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS SIG TITLE Corporate Secretary DATE 11 /19/03 4 rI od Aw } �j k• 4'� i i1i' \I C 5 1 Tr �y.l�•, .� ar -�.. DEPARTMENT SE ONLY j �( Application Accepted By Date 'lJ Area r f mployee Grout Inspection By Date ❑ SPECIAL Well permit f Pump Inspection By Date -/ ❑ WAIVER Received €G Destruction Inspection Date two Constructed Well Depth ft I COMMENTS LZW �'�� - /� r T�r "4 /�u ►?� !lam !_�� PE SC Amount ck#! Received Permit! [ I Codes Info Remitted Cash [Iv Date Service Request 4 Invoice# Well IDq 3� 1 L15- 93 F„r"/ rF:R wA :€1 w I t. t 4 EHD 43-02-006 / F sn/z002 �i,rx-T `re��