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, 'CV V.LL I rUivlr r VI 14-irIY i SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT: /NT 304 E WEuFR AVL-S'1'OCK'1'ON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT CALL.(209)953-7697 FOR I.NSPECTIO\S E ES I YEAR FROM DATG ISSUED FAs y JOB ADDRESS 18882 E. Gawne (parcels behind CITY1ZtP I;1[7017kt-C)n CA 3D ° CROSS STREET Nelson (PA#03369 ) APN I ✓ r✓" PARCEL SIZE 4-acresV f OWNER NAME Stacey Griffith PHONE OWNER ADDRESS 11875 E. Mayers Rd. CITY/STATE/ZIP Acampo, Ca 95220 CONTRACTOR Purviance Drillers, Inc. PHONE 209-887-3554 CONTRACTOR ADDRESS P. 0. BOX 64'/ZIP Linden, Ca 95236 SUBCONTRACTOR PHONE r SUBCONTRACTOR ADDRESS C]TV/STA'['E/ZIP 7131 /05- LICENSE C-57 [3C-6l ❑D-09 ❑Other NUMBER EXPIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE ❑Domestic/private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization ❑Public Water System Ifdifferenr fromOwner: aier system Name Contact ame or one um r m TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other num ❑Soil ber of wells number of horings ❑Geotechnical number of horings r ❑Monitoring Welt(s) Boring(s) [3 Well Destruction ❑Out-Of-Service We]1 ❑Out-Of-Service Well Renewal ❑New Pum ❑Pump Replacement 0 Pump Repair Crass-Connection Repair WELL CONS•I'RU(7I0N Drilling Method ❑Mud Rotary ❑Air Ruutty ❑Auger ❑Cable Tool ❑Push Point ❑Other Proposed Well Depth ft Excavation in diameter ❑Open Bullotn ❑Gravel Pack/Gravel Size in diameter ❑Conductor Casing in diameter 1 Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sehed ❑Steel ❑Plastic ❑Stainless Steel ❑Other Grout Sea[ Depth ft ❑Neat Cement(941h hug/5-10 gal water) ❑Sand Cement suck mix 17 gal water ❑Bentonite(20°/u solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Grout Placement Method ❑Pumped ❑Free Fall 0 Other ❑Retardant 1 Accelerator(name) PEDESUAL Installed By ❑Driller ❑Pump Contractor ❑Other ❑Concrete Pedestal Dimensions: Width ft Length it Thick in ❑Christy Box Q Stove Pipe PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set tt Standing Water Level ft WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other Well Diameter in Tota]Depth ft Depth to Water ft ❑Casing to be Perforated from ft to ft Scaling Material ❑Neat Cement(94 Ih hug/5-!Oral wafer) ❑Sand Cement .cock min/7 gal water 0 Bentonite Pellets ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on bile ❑Specs Submitted Placement Method ❑Pumped ❑Free Fall ❑Other ❑Complete with Mushroom Cap ft below grade ❑Complete to Existing Surface Pad 1 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 CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITII ALL, WORKERS COMPENSATION LAWS. -M2 UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS—PLEASE CALL(209)953-7697 SIC. TITL£Cor orate Secretary DATE 1 2/4/0 3 4:h-Irt l-1 .1 !U R D E T L T pE )Af TM FF +w ')I:PAR'f>1l•a'1'UtiE till`/ Arra— �— !Employee 1D4 Application Accepted By Date Grout Inspection By Dale ❑ SPECIAL Well Permit Pump Inspection By _ Dau - ❑ WnlvElt Received Destnrction Inspection 11 _ — /Sale Af Construrted Well eeptthh�/_�� fl COMMENTS lie PE SC Receive cc Amount Date Permit! Invoice# Well IDlF Codes In B ash Fte ted Scrvicc Rc uest# N 5 0 00 ( ` a MASTER WATER WELL PERMIT EHD 43-02-006 12/6/2002