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• INELL/PUMP PERMIT <br /> SAN JOAQUW COUNTYENVIRONFAENTAL HEALTH DEPARrAMT 7868 EASrHA�TON AVENUE-STOCKTou CA 95205-(209)468-3420 <br /> MON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED m <br /> JOB ADDRESS <br /> 5910 N Davis Rd C,TY1zP Lodi, 95242 n <br /> -030-01 <br /> ACEL S _ UAPPCATONT <br /> APN027L6���� 209-3 <br /> OWNER NAME ' Don Wortley RHONE <br /> S <br /> N <br /> 1591:;0 N Davis Rd Cm15rnT>ILP Lodi, CA 95242 <br /> OwNE.4 AODRtSS <br /> CoNTRAQTOR Purviance Drillers , Inc PHONE 209-887-3554 <br /> Co�rrRACTOR AOOR65 <br /> PO box 64 CrT1STAT0PLinden , CA 95236 <br /> PHOhc <br /> ISUBCOtsi'dACTOR <br /> SUBCONTRACTOR ADDRESS CITYISTAT80P <br /> UmsE n C 7� 0 C-M .3 D-69 n ets <br /> Other Nul-t 3 7 7 A ;_23 EuawnoN DAT7/31/ <br /> DomEsncW-;a.LSAmPt-inm D.General MineraUCal'dotm Bacteria(4391)=Dblamachlompmpane(4392) Arsenic(4393) i <br /> tNrENDED USE ^Oomestic/Privale P Irrigation/Agncullural G Industrial C.Water Quality Monitoring D Soil Sampling/Chataderization 1 <br /> 0 Public Water System <br /> tfcWexentfmmNner- 1.1.1r.1ysimNerre C°r4zriNarn^°rPn°naNumber A _I1 <br /> TYPE OF WORK ,x New Well C Replacement Well C Well AlteravoMllodiification 7 Other ��r <br /> D Monitoring Well(s) mafwells G Sol?Borings) aor Codngs C Geotechnical '0f 0o""� ��I1 1� <br /> G Out-OfSelvice Well C Out-O`Service Well Reneral 7 Cross-Connection Repair <br /> 0 New Pump c Pump Replacement C:Pump Repair .3 Raise Well Casing ��T <br /> WELL CONSTRUCTION f X019 <br /> 7t,TillingMethod)(Mud Rotary r'Air Rotary D Auger 7 Cable Tool -3 Push Paint Other SAAO <br /> Proposed Well Depth 3CO ft Excavation /jZ'ISJ. in drarneter WOpen1lottom C Gravel PacklGravel Sae in dierneler 1RoNM COUN <br /> TY <br /> Conductor Casing 1, dre <br /> inmeler I Conductor Casing]Depth fl ElVT <br /> I Well Casing Di meier�in ThickneWGaugelASTM Sched./r e =Steel 0 Plastic D Stemless Steel ]Other I H DEPART N1. <br /> Grout Seal Depth 2090(f D Neat Cement(941b bad->70 gal vrateo -W Send cement fid• 3 sack mnd7 gal vrater <br /> G Bentonite(20%solids) J Olher <br /> Grout Placement Method Pumped 0 Free Fall 7 Other J Retardant I Accelerator(name) <br /> PEDESTAL Installed 6y Driller -3 Pump Contractor 0 Other <br /> �ConcretePdestalCDlmensions-Width P Lenglh ft Thick in �ChrlstyBoz �SmvePlpe <br /> Pun1P Submersibte0 Turbine 7 Other HP PUMPS ft Standing Water Level it <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THS APPLICATION AND THAT THE WORK WILL BE DONE IN,ACCORDANCE WITH SAN <br /> JOAQUIN 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 /> WOR MPENSATION LAWS- <br /> MINI UM 2 VANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL.(209}953-7697 <br /> stair T,,,�Corporate Secreta-LATE 10/7/1 9 <br /> III II I I I11 1 f I I III <br /> ! II I II I il ! I <br /> III If II II 1 11. 1J, f II llll I <br /> III I III li ! I Illilll <br /> II ! i I I I III ilil <br /> 111 <br /> III I III11 I I` <br /> Il I ( II I I I <br /> III ! I ! I I ! ! <br /> l I II III { II I I <br /> I I I I I I I I I <br /> I i I I I I I -7—IFT77-1 1H <br /> I I it II II II 1111111 <br /> , III � Il I il ! I II <br /> I I I I I I I I I I I I I I <br /> I IIII <br /> I I II I I II <br /> I ( I I JI FT I I 1 <br /> AR MENT US 0 LY <br /> Application Accepted By / tB Area Employee IM <br /> Grout Inspection By Date /b�11 (tR � PECIAL WeII Permit <br /> Pump Inspection By C� k Date U 11/l�; ❑ WAIvER Received <br /> Sail Raring Insp/ecItion By Date 's COr�stga(ted Well Depth Lj O V R <br /> � <br /> COMMENTS�,y//��� l2/(l/� Yi� �1� �-�4A LFS i t�D FsI� zIt., 7 <br /> PE SC Reeehrad Chadd? Amount Date Permit/ (nvoirxR Welllt� <br /> Code .. In . _ _ ----_Remitted S ice-Reguest: I-- <br /> - G I I <br /> ` I <br /> wa-L RU:S PE-RLtrr <br />