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SAN .IOA(JuIN COUNTY <br />i <br />0086•ON OKI[ LIE '66'Daa IWIJ paAi;3;� <br />oo WELL/PUMP PERMIT <br />P ✓r� <br />HEALTH DEPARTAENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-2420 <br />CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />Flood Rd r—,x,o Linden <br />CROSS ST EET Fine Rd APNO/3o90/�PARCEL $ ,! <br />LAND USE APPLICATION # <br />OWNERN MELeOnardini Trost ;3aro Q J L.QOna HONE 209-481-2203 <br />OWNERAIPDRESS 6 6 01 N f i n e R d y �p 4,rrfSTATFj7iP Linden , CA 9 5 2 <br />CONTRACTOR Purviance Drillers, Inc PHONE 209-887-3554 <br />CONTRACI ADDRESS P O B o x 64 _ Cmr/STAnVap Linden , C a 95236 1 <br />n <br />v <br />w <br />LS ONACTOR _ PHONE <br />Su9cON ACTOR ADDRESS CITYISTATEl21P <br />LICENSE C_57 C-61 ❑ D-09 D Omer NUMBER 37792 3 E...TON DATE 7/ 3 1/ 19 <br />I <br />DomF-s7ic WELL SAMPUNe_ P General Mineral/Coliform Bactena (4391) t: Dibromochloropropane (4392) :1 Arsenic (4393) <br />INTENDED I isE D DomesGclPrivate fainigation/Agricultural [i Industrie[ TIWater Quality Monitoring C Soil SamplinglChareclerization <br />D PUbliC Nater $ytent <br />o <br />dfare u <br />N tll Rerer4 from Dormer Water System Noma Conlan Name or Pnorc NUTEei \rnJ <br />TYPE OF ORK III New Well ❑ Replacement Well D We[ AAeratioNMDdification 0 Other <br />U MonlIunng Well(s) #ofwe!!s C Soil Bor[ng(s) 4oruorirV5 G Geotechnical 'r 0r "ngs <br />U Cut•Of-Service VVeU ❑ Oul-OfService Well Renewal ❑ Cross -Connection Repair <br />n New Pump D Pump Replacement ❑ Pump Repair ❑ Raise Well CasingL� <br />WELLCo ;TRUCTION <br />DrillingM thud * Mud Ro L Alr Rotary 0 Auger D Cable Tool ❑ Push Pant ❑ Other <br />A <br />Proposed Well Depth s2`b r <br />P p fl Excavation � / 'L in diameter !Open Bottom G Gravel PacklGa-mrel SPzie in diameter <br />C Conductor Casing in diameter / Conductor Casing Depth R <br />u Well Ca ilng Diameter in Thidmess/Gauge/ASTM Srhed , 2-5�2I = Steel ❑ Plastic 0 Stainless Steel D Other <br />— omlli <br />�-1 GroutSeal Depth Lo O (-4-) ft a Neat Cement (941b bagb10gat water) IF Sand Cement 10. 3 sack r4xl7 gal water <br />0 Bentonite (20% solids) D Other <br />Grout Pla ement Method; Pumped ❑ Free Fall ❑ Other 0 Retardant f Acceleralar (name) <br />PEDESTAL Installed By :Fgpuller 0 Pump Contractor ❑ Other <br />:7 Concrete Pedestal LDimenslons Width ft Length fi Thick in n Christy Boz C Stove Pipe <br />PUMP n SubmersibleC Turbine 7 Other HP Pump Set ft Standing Water Level ff Ae�� <br />I HEREBY CERTIFY THAT I HAVE <br />D THS APPLICATION <br />D THAT THE WORK VALL BE <br />NE IN ACCORDANCE WITH SAN <br />COUNTY <br />ICENSE IS <br />CURRE-JOAQUINT AND ACTIVE WITH THESTATECAUF40 NIA CODRULES ANDNTRACTORS STATE CENSE BOARD AND THAEGULATIONS. I ALSO T OI AM N COMPLANCTHAT MY REQUIREDE WITH ALL <br />--77 <br />WOR <br />IKEM MPENSATION <br />IN) M 24NCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (2!09)953-7697 AN OVc® <br />SME ` T�TL,rCorpor Sectary DATE 12/27/.L JO ?Oj� <br />qQV/H <br />qRHcon <br />4h71y <br />rMFHT <br />s: m <br />I —T`` < <br />I ti tor+ <br />Ron <br />z co <br />x <br />C <br />COMMENT <br />:•• <br />P ( R T M E N T S E ONLY <br />Appli 'on Accepted BY <br />5UaZE <br />Date L <br />Area Employee 1Dd <br />Gr t IrrspecUon <br />Date <br />SPECI L W911 Permit <br />P p Inspection <br />IVIDate <br />_7 WAIVER Received <br />Soil Bor ng Inspecti%% <br />Date <br />Consovcted Well Depth <br />ft <br />COMMENT <br />:•• <br />W BMW <br />_� <br />EFID43-05 I <br />n6 �� ^-rte VJELLl.UMPPzRMrr <br />9•d tZgU2860Z �17`I1/l Out Saalll_l(] aouelAind eZZ: 6 L Z L 6Z oaa <br />