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B IN Wd1S : H 8101 '18 '2nd mil paAl ;);d <br /> r WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENviRo,4mENTAL HEALT14 DEPARTMENT 1868 EAST HAzELToN AVENUE-STOCKTON CA 95205-(209)4611.342D <br /> NON-REFUNDABLE PERWT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 9 YEAR FROM DATE ISSUED <br /> N <br /> JOB ADDRESS 6909 Cox Rd crrympLinden Ca 95236 m. <br /> CROSS STREETC o m s t o c k Rd AP /� PAACEI SIZE 7D(15E APPLCATION'� <br /> QwNER NAME Torn Whi teGi dam} _ _ _ ON 09-403-9194 <br /> OWra-R AODRE" P - Q-- Bog 182 cmusrwizipLinden CA 95236 <br /> CONTRACTOR P irviance Drillers , Inc PHONE 209-887-3554 <br /> CONTRACTOR ADDRESS PO Box 64 CRYISTATEIDPL i n d e n , CA 95230 <br /> SUBCONTRACTOR Pliom <br /> SUBCOr)TRACTOR ADDRESS CMISTATEIZIP <br /> UcFNsE -X C-57 a C-61 7 D-09 ❑Other NUMBER 377923 Expi A icw DATE 7/31 /19 <br /> DOMESTIC WELL SAMPLING:00 General Mineraitcoliforn Bacteria(4391)=Dibromochloropropane(4392)7 Arsenic(4393) <br /> INYENOED USE KDarnestic/Privat9 G IrrigationlAgdcultural G Industrial G Water Quality Monitoring D Soil SamplingrCharaderizalion <br /> C Public Wder System <br /> lydFemrahorn Owner- blazer SyslemWme Conrad Naxe a:Pncae Nrmabc <br /> TYPE OF WORK (2 Neer Well C Replacement WeTi D Well AlteralionrMoi ification 7 Other <br /> D Monitoring We9(s) R of wells G Soil Boring(s) '0r°O"as D Geotechnical s ort°n gs AYNjE <br /> C Out-01 Sc vice Weg C Oul-Of-Service Wes Renewal 7 Cross-Connection Repair Nr <br /> D New Pum Pum R Iacement G Purnp Repair 7 Raise Well CasingEVE <br /> WELL CONS-MuCITON D <br /> Drllling Method G Mud Rotary r:Air Rotary 0 Auger 7 Cable Tool D Push Point D 011ier C /- <br /> b <br /> Proposed Well Depth ft E—vation in diameter D Open Bottom G Gravel PacJUGravei Size in diameter O 201D <br /> D Conductor Casing in diameter J Conductor Casing Depth ft J Q <br /> Well Casing Diameter_in ThidmesslGaugeJASTM Schad =Steel 7 Plastic C Stainless Steel 7 Other QUIN COVN]y <br /> Grout Seat Depth ft 3 Neat Cement(441bbag(-'f0galrvater) 3 Sand Cement SaarmorrJ %t ONMEIO <br /> G Bentcnite(20%solids) ❑Other 1)ER4R7NT <br /> Grout Placement Method G Pumped D Free Fag D Other 7 Retardant IAccelerator(name) <br /> PEDESTAL Installed By D Driller 3 Pump Contractor D Other <br /> G Concrete Pedestal COimenstons:Wldlh R Length If Thick in -1 Christy Box 3 Stove Pipe <br /> PUMP Submersible❑Turbine 3 Other HP Pump Se If Standing Water Level ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK ILVRL 13E DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED USE IS <br /> CURRENT AND ACTIVE WITH THE CALfFORN1A CONTRACTORS STATE LICENSE aOARD AND THAT 1 AM IN COMPLIANCE Wi 1-< _ CO <br /> PENSATIOH LAWS. <br /> M1N1 511 ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 r� <br /> SIGNTRLS o r p o r a t e S e c r e t a r yATE-777 F <br /> i � <br /> CD <br /> I7_b <br /> _ X <br /> CL <br /> 1777) <br /> v . O <br /> r_7 � <br /> I <br /> i <br /> EP RTMENT UfSE y <br /> Application Accepted By - Date Area GrnploYee ID#AWQ - 1 <br /> Grout Inspection By Date �[ PECI Well Permit <br /> Pump Inspection By Date II WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well De Dt R <br /> COMMENTS <br /> PE SC Received Check#/ Amount Parini <br /> Cods Info 9 ash ._ Remitted Date S rvice Request Invoiced VJe01D>k <br /> 6,,- <br /> I <br /> EHD 41-eo COtltb U �J3d3�G Yt y.l rPUh!P PcR61IT <br /> 8'd bLSEL8860Z OUB Saallua aoueiA-Ind eV7: 9� 68 6nV <br />