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HOPON AVLO : [ [ 8lH 8 q a j awil paAI@ <br /> t WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EASTHAZELTON AVENUE-STOCNTON CA 95205-(2D9)468.3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joe ADDRESS 21409 E Flood CITYlZIP Linden <br /> CROSSSTREET PAPNI <br /> PARCEL SIzejr•nD <br /> LAND USE APPL]CATION'# ° <br /> OWNER NAME Mike Gandolfo PHONE y <br /> OWNER ADDRESS p O BOX 673 � c,TYrsTATElzJPL i Ti d e n , CA 9-5236 <br /> CONTRACTOR Purviance Drillers , IIIc . PHDNE209-8R7-3554 <br /> CONTRACTOR ADDRESS P O.Box 64 CITYISTATE0,L i n d e n , CA 95 2 3 6 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS_ C"YISTATE/2:IP <br /> LICENSE IXC-57 IJ C-61 J D-09 L Other NUMBER ExP,TtAT1ON DATE <br /> GEOGRAPHICAL I NFORMA71ON: Coordinat"X V Township_ Range Section_ <br /> INTENDED USE a DomastioPrivate J IrTigatioNAgricukural 'J Industrial C Water Quality Monitoring F.1 Soil Sampling ICharaderization !N0. <br /> ii Public Water System <br /> It aiflerenl from Owner. a er ys ern ame un ea ame o ane um /�pA <br /> TYPE O>:WORK �i New Well Replacement Well J WeII Atteration/Moditation L Other <br /> of'"1 s ® S <br /> F Monitoring wen(s) of wells IJ SOII Borings) 9 - GeeteChnical far AO"�S rl 1 <br /> Out-O:-Service Wall n Oul-Of-Service Well Renewal - Cross-Connection Repair -34,/V 2 .� <br /> -New?cm Pum R laoemen[ n Pum R air 4 <br /> Raise Well Casin ✓0 (N <br /> WELL CONSTRUCTION <br /> Drilling Method u Mud Rotary L Air Rotary Auger U Cable Tool J Push Point a Other H�CTN p M�NT� <br /> Proposed Well Depth fl Excavat en in diameter J Open Bottom J Gravel Pack/Gravel Size in diameter a�TMFNT <br /> Li Ccnduct�f Casing in diameter I Conductor Casing Depth_ft <br /> Well Casing Diameter �/ in Thickness/Gauge/ASTM Sched &Steel F Plastic _ Stainless Steel ❑Other <br /> Grout Seal Depth_h U Neat Cement(94 1b bag�5-10 gal wafer) -7 Sand Cement sack mixt)gal water <br /> BKdcnfte(2C%solids) I Other <br /> Grout Placement Method D Pumped Il Free Fall -1 Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By tJ Driller ❑Pump Contractor C Other <br /> I I Concrete Pedestal I_Dimensions•Width R Length ft Thick m L Christy Box U Stove Pipe <br /> Pump .I Submersible_Turbine 'J Other HP Pump Sel ft Slandirg'Naterlevet ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORT(WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQU IN 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 /> WO COMPENSATIO <br /> MI MUM O ANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGN TITLE Corporate Secreta-&yi, 2/5/18 <br /> M <br /> /V t■II� <br /> z <br /> C <br /> MO M <br /> t� <br /> r±FT <br /> _ C <br /> iT1 p <br /> EP RTMENT U E f�V�LY AS?IIAL <br /> �ADp!icationAccepted By Date GQAmaEmployeeID#�A4= <br /> Grout Inspection ey Date Well Permit <br /> t �i�A Inspection ey {7dte ul WAIVER Received <br /> Sail Boring Inspect'on By Date Construct 4rt1 Depth ft <br /> COMMENTSe <br /> a <br /> PE Sc Received Chi Amount Permit) � FJlt <br /> Codes Info B Cash Remitted Date Service Request k Invoice M Well 10# <br /> - Z Z:' 211 <br /> EHD43-CO /� A <br /> 4130112 /i�„ [ _ 7'1/\/�/�T WFU IrUMP PEFNIIT <br /> Z'd VZSEZ9960Z J" (j�J out SJejji.lQ aOueiAind d6Z:ZL 2 80 gazj <br />