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6tiSl '°N AVW6 LIH 'ZZ'APA awil paAI;D;� <br />WELUPUMP PERMIT <br />SAN.JDAUUIN Co11,VTY EMV RONMEWAL HEALTH DEPARTMENT IWS EAST HAZCITON AVENUE - STOCKTOM CA 9S2115 - 17nv1 dAR- It <br />NUIM-KEFUNDABLE PERMIT CALL (2091953-7697 FOR INSPECTIONS EXPIRES i YEARFROM DATE ISSUED <br />JOBAoDREss 4989 E Armstrong C-rnz, Stockton, <br />CROSS SHEET I 99 Frontage APN I(% ��� <br />PARCEL SIZE �� ND USE APPLicAno^)# <br />Owr1ER TuulE Robert Tanaka PHON£ <br />O ANIR ADDRESS 11031 E. Baker Rd CMISTATEl7JP Linden, C A 95215 <br />(CONTRACTOR Purviance Drillers, Inc. PHONE 209-887-3554 <br />CONTRACTOR Aowmss �� 0` ROx 64 Linden <br />i CITYtsTATFlZlP , CA 9 5 2 3 <br />Suecomm-ACTOR PHONE <br />SUBCOUTRACTOR ADDRESS <br />LrcFaxsE LYC-57 _ C-67 D-09 <br />CITYiSTATFJ21P <br />NUMaER 377923 E1tPIRnnoN DATE 7/31/17 <br />LaECGRAPHICAL INFORMATMU: Coordinates X Y Township_ Range Section_ <br />I KTENDt31 USE d Oomaslic/Privatu C Inigalion/Ag6cuftural Industrial - Water Quality Moniloring Soil Sampling/Characferizafion <br />Pubic Wafer System <br />I tt dinereti rnm Onncr acv ys em. arc n;aa as or .-,ane u r <br />TYPE OF WORK _ New Well Replacement Well :., Weli Aiteralion/MOdi6ca lion -i Other <br />MonitoringWe!I(s) gotviells SoilBomg(s) "orbcriw f Geotechnical of borings <br />_ Out-OfSe vicevTye11 :7Out-Of-Serrice West—, ^ Cross-C.eclion Repair <br />.'. New Pum ✓_' Purn Replacemen[ Purnp Repair = Raise Well Casing <br />WELL CONSTRUCTIWI <br />Drilling Method Mud Rotary _ AY RDtary .. Auger _ Cable Tcol Push Point L Other <br />Proposed Well Depth fl Excauat art in diarneler - Open Bottom —, Gravel Par]dGravel Size in diameter <br />_ Conductor Casing in diameter 1 Conductor Casing Depth ft <br />Well Casing Diameber_ "rn ThicknesslGaugeJASTM Sched I:: Steel a Plastic Stainless Steel O Other <br />GfoutSeal Depth n _ Neat Cement(941bbag'S-TOgalwafer) =Sand Cement saUrrlix7galwater <br />Bentonite (209hPJ <br />5 solids) : ot <br />Grout Placement Medved G Pumped Q Free Fall -- other Retardant f Accelerator (name) <br />PEDESTAL Installed By a Driller Pump Contlecror Other <br />Concrete Pedestal: Dimensions:VVidth n Length n Thick in ;: GhrlsryHoc U Stove Pipa <br />PubtP Mubmersble[: Turbine Other HP Pump Set n Standing Vdaier Leuel rt l <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DOME IN ACCORDANCE WITH SAN! <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CODITRACTORS STATE LICENSE BOARD AND THAT t AM IN COMPLIANCE WITH ALL <br />24 ; AD NCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />Ta. Corporate Secretor 7 <br />I E.P RTMENT ,.,SnE NLY <br />ApplicalionAccepfed By Date vv Aram EmployeeID9�10 <br />77 <br />Grout Inspection By pale D SPECIAL Well Permit <br />Pump Inspection Date- L I Z,O � C�' = WAVER Received <br />Sal eodrla inReclion gY i pate T Constructed Well Depth t <br />=HD 12 LS :ZL IPUhIP 7ERt.l^. <br />CAD <br />Z'd tZgU2260Z Dui Slell!]Q aOueiAind <br />T <br />D <br />v <br />0 <br />a <br />m <br />w <br />M <br />M <br />�0 <br />M <br />tv �, <br />N <br />O <br />d5£:V0 ZO OZ oaQ <br />ved Chect�l <br />Cash <br />Amount <br />Remlhed <br />Date <br />Permit/ Invoice# Well 00 <br />Service Request # <br />1;sem <br />o,'r <br />`�-1 <br />16--30- <br />=HD 12 LS :ZL IPUhIP 7ERt.l^. <br />CAD <br />Z'd tZgU2260Z Dui Slell!]Q aOueiAind <br />T <br />D <br />v <br />0 <br />a <br />m <br />w <br />M <br />M <br />�0 <br />M <br />tv �, <br />N <br />O <br />d5£:V0 ZO OZ oaQ <br />