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ILS "N AdSI:E EH '8I 'APA ;W1j paAl;);� <br />WELL/PUMP PERMIT P✓ <br />SAN JQAQUM CavMV ERvIRONMENTAi HEALTH DEPARTMENT 1868 EAST HAgtiON AvmuE - Smc KTau CA 95203 • (209)468-342o <br />NON-REFUNDABLE PERImIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br />�JoEt ADDRESS 9409 E .sat-- Hwy 88 c,m,_Stockton Ca Gds ZI> <br />a,o,ssT r B o g g i a n o R d AM - -moi P..S.. LAND USEAawLAno%V <br />OWNER t'tArAE Lawrence Samhado8G ctm Wa ,�e�L. �09-931-2568 <br />OrvnaR AODRE3s P. 0. Box 0 CfTYISZATEZpL i n d e n CA 95236 <br />CoNraacTon Purviance Drillers, Inc PHONE 209-887-3554 <br />ComTRAcroR ADCREss PO Bag 54 c1STATEjz,,L i n d e n, CA 95236 <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS 11CITYISTATFJZIP <br />L10EmsE C57 '0 C-61 0 D409 L1 Cline, NUMBIItJ / �""�� EYPIRATICN DATE <br />DouesTTc WELL SAvipLINa: O General Mineral/Coliform Bacteria (4391) _ Dibromochlompropane (4392) Arsenic (4393) <br />INTENDED USE DomesticJPmrate ❑ IrrfgationlAgdarllura) C Indus' al G Water Quality Morctodng O Sol SemprnglChaaderimfion <br />❑ Public Wale System <br />Ir Vftevol from owrr�: Water System Nvm CmCnq Norm at Phone N.ntb <br />TYPEOF WORK C rL-y Vvel7 C Replacement Vef C VMI AlFcalton/Modificabon 2 Other <br />n MonKWng Welts) 4 Dfvrells o Soil soTtnq(s) =c1bonngs r Geoieamical ace honngs <br />0 Out-OFServiceW O C Out -Of -Service Well Renews] J Cros-Conneclion Repair '" <br />IDrUling Method D Mud Rotary C Ar Roby .3Auger p Cable Tool D Push Point O Other <br />Proposed Well Depth h Excavation in diameter 0 Open Bottom C Gravel Pa&JGravel Size in diameter <br />D ConduCorCesing Fn dLameter / Conductor Casing Depth ft <br />Well Casing D ameter_ in TWcicness/GaupeIASTM Schell 0 Steel D Plasmc 0 Stainless Steed 0 011ier <br />G rout Seat Cepth R D Neat Cement (94 lb Deg/S10ga1 rralerJ .3 Sand Cement sack mbdl gel vieter <br />Il Berdonft(2a%solids) r1 0trw <br />GfoutPlacarmntMethod C Pumped C Free Fall 0Other O Retardant J Accelerator (name) <br />(PEDESTAL Installed By D Griller 3 Pump Cantiedor D Other <br />D Can trete Pedestal C'. Dim ensiorrs: Width R Lenalh __ ftTtiirk _ in 7 ChrtStV Bogy -71 Smve Pina <br />PUP SubmersiDleO Turbine D ORrer HP / fV Prmp Set U Standing VVAer Level ft <br />I HEREBY CFR FY THAT 1 HAVE PREPARED THFS APPUCATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JDAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT PJY REQUIRID LICENSE IS <br />CURRENT AND ACTIVE NVITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE IW H ALL <br />NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />f,►� r,�crporate Secretar&,E <br />W <br />�a <br />a <br />20 <br />m <br />4444■■■■;�■■■■■■■■■■■■■■■■>.�• �:����r�■■■w■■■w■a■ .. <br />��■■II�SI!ll�1�a�■■a■a■■■■■�!!■■■■a■i:�'�■t■■a■�■i■�iL • • ' <br />alYii■W■LliiY■■■■�■■■■■■■�y�1i10■■■��■■■■■!•■i■■■1•■ ' • • - ' <br />EPA TMENTr SE NLY �j�(� <br />Application Accepted By Date Area Employee ID tk�= <br />Groullnspeceoneyo�( Date l7 SPECIAL Well Permit <br />Puma Inspection By (- "v Date U i j14 w(C1 WA[vER Reeehred <br />Soll Boring Inspection By Dale Cofmtiscted Well Depth it <br />COMMENTS <br />EAD43-03 envie V.SLL1PU'�.P?Eae.4T <br />7'dtiL9EL8860Z OUB SaauQ <br />��GOUeiAind d89'.Z0 8L 8L AeW <br />