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)lilELUPLIMP PERMIT <br /> SAN JOAQUIN CCUNTYENv1RONmENTAL HEALTH DEPAR-ImENT T esa EASTHAmTON AVENUE-STOCKTON CA 95205-(209)468,U20 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> 910 N Davis Rd C,n/z,. Lodi , 95242 <br /> (JOS ADDRESS ��/ D <br /> CaossS-mmr APN 0 27-0 3 0-01 as. /L/. USE APPLICATION' a <br /> Don Wortley PHONE 209-369-2914 N <br /> OWNER NAME m <br /> OWN�AoaREss <br /> 1591:0 N Davis Rd CtrrISrATFJZP Lodi, CA 95242 <br /> CONTRACTOR Purviance Drillers , Inc PHONE 209-887-3554 <br /> CO.'aRACTOR ADDRESS PO Dox 64 C1TYISZA1ElZIPL i n 6 e n, C A 95236 <br /> (SUBCONTRACTOR PRONE <br /> SUBCONTRACTOR ADDRESS CnY1S fATEfZ P <br /> LICENSE rt C-V u C-67 D D-an D other NumBER 3 7 1 9 2 3 ExPmAnoN DATE 7/31/ <br /> Doltes'rr VUR I SA piffi .D General MinerallColifoml Bacteria(4391)=Dinromochlomprapane(4392) Arsenic(4393) V <br /> INTENDED USE X DomestirlPrivale G ImgationfAgricultural C Industrial G Water Quality Monitoring O Sail SampltnglChataderization 1 <br /> LI Public Water System <br /> UdilWrenl fmm Owner- lffl7erSystam nine Cordae Nan,.-ar Pnon_Number _ <br /> TYPEOFWORK ,x New Well C Replacement Well C Well AlterationWor fication 7 Other r-4 Y �yP,B� <br /> mofbwings G Geotennicalmtrgs c v <br /> n Monitoring Wells) ;r of\Netts G Sail HDring(s} ="b �' <br /> G <br /> Out-Of-Service Well r Out-Of.-Service Well Reneral 7 Cross-Connection Repair <br /> 0 New Pump C Pump Replacement %Pump Repair ]Raise Well Casing <br /> /y <br /> WELL CONSTRUCTION / 2019 <br /> ;n fingMethod)(Mud Rotary G AirRotery 7 Auger ❑Cable Tool -1 Push Point :'- Other O 1J <br /> Proposed Well Depth 3CC It Excavation�in diameter Open Bottom G Gravel PacidGravel Size in d meter IRONM cc <br /> G Conductor Casing��in diameler 1 ConductDr Casing Depth H DEP PNjA> <br /> Well Casing Dh�nePl�in Thidmess/GaugelASTMSdted./-i, =Stee) D PlaSlir C Stainless Steel ]01her I ARTAfE11/T <br /> Crout Seat Depth 04)&- 3 Neat Cement(94 Ib bad-}70 gat vrateo -9f Send Cement /0• 3 sack r*fT gal Water <br /> C Bentonite(20%Solids) J Other <br /> Grout PiacementMethad jk9umped D Free Fall 7 Other G Retardant/Accelerator(name) <br /> PEDESTAL Installed 6y Driller 7 Pump COnlraCtor D Other <br /> Can <br /> P tlestal CDlmensions:Widtb ft Length It Thick in �Ctnisty Box J Stove Pipe <br /> PlIM11P SubmersibleD Turbine 7 Other HP Pump Set ft Standing Water Level It <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WfTH SAN <br /> JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS- I ALSO CERTIFY THAT MY REQUIRED LICENSE 15 <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT t AM IN COMPLIANCE WITH ALL <br /> NOR MPENSA710N 11LWS- <br /> MINI UM 2 !iIWVAMCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(2091953-7677 9 <br /> + <br /> SrcN T, sCorporate SecretaryJil10/7 1I <br /> III If I I III I I ! <br /> I II I I I il ! I <br /> III II I I II l 11 III I <br /> ill I III II I 1111111 <br /> II I I ! I I llI I <br /> II I Till <br /> 111 I III A I I I � Ilil <br /> II flll f I I <br /> III l1 IylI I I I <br /> ! I IILl II III ' <br /> III j I I II II III I I I , <br /> II11 I II II II I II II I <br /> ! Il I fl I II <br /> III I I I II I I I I II <br /> ! ( III <br /> I I II ! ! <br /> III I I I I i <br /> AR NtENT USV OPILY <br /> Application Accepted By <br /> Area Employee ID9 <br /> Grout Inspection By Date fI7 r 1 ``` PECIAL Well Permit <br /> Pump Inspection BY l U^ >ra CSL. �1. Data U 1 L/9n O WAIVER Received <br /> Sal Baring�Inspection_By Date—� Co d Well Depth 400 b0 R <br /> COMMENTS <br /> PE SC Received Chaeidll Amount PermiU lnvaice# I WelllD9 <br /> Date .. S r dee-Request;- <br /> Code -- In -- — _- _--- -- -•-----Remitted <br /> I I C <br /> I <br /> f <br /> vn�r-r:ur Pour <br /> EHp:7-,.� efaTns <br />