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9521 "N AVLS:ll L06 '8 'rias ;WI j paAia0a� <br />N <br />WELUPUMP PERMIT <br />SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EASTHAZELTONAvENU@-STOCKTON CA 95205 - (209) 4683420 <br />NON-REFUNDABLE PERMIT CALL (209) 963-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />Joe ADDRESS /8299 <br />� 2 9 9a �-N Beecher <br />ye ne c h e r Rd (/Q ciTwzS t_ o c k t o n 95215 <br />CRDLSS STREET L. -Om rd'FDC-!G J? APN QD -1 14 V 13 PARCEL SIS i�.3 y LAUD USE APPLICATION 0 <br />OWNERNAME FrankOStonebarger J n'yarc�a -T.,— Ptame209=401-6790 <br />WN <br />DER MDMM 8408 N Beecher RD c„�STATEIZIP Stockton 95215 <br />::OWMACTOR Purviance Drillers, Inc. F,,.209-887-3554 <br />CONTRACTOR ADDRESS P• 0 •Box 64 CITrrSTATFIzP Linden, EA 95236_ <br />SUBCONTRACTOR PHONE <br />1cTOR ADDRESS <br />C-57 a C-61 j D.09 _ <br />CITYISTATEJZIP <br />NUMBER 3 7 7 9_ 3 ExPIRAnON DATE 7/ 3 1 q <br />GEOGRAPHICAL INFORMAIIOY_ COOrdinates X Y Township_ Range Section_ <br />I NTENDED USE _ DomesIc/Pnvate IflnigationtAgricultural L Industrial D Water Quality Monitoring O Soil Sampling/CharaCterizatlon <br />Public Water System <br />1.' lfiff nt from air. n ry em on a ami or one u r <br />TVPEOFWORK U New Well Replacement Well U Well ABeraCortfModtficaton Other <br />; I Monitoring Wells) # of wells : i Soil Baring(s) a or eodr,jr, Geotechnical _ V of 1O1;Oro <br />`I Out -Cf -Service Well :'I Out-OfSenice Well Renewal Cross -Connection Repair <br />Drilling Method _ Mud Rotary :. Air Rotary _I Auger ., Cable Tool Push Point , i Other <br />Proposed Well Depth fl E)=vstlon in diameter Il Open Bottom = Gravel Pack/Gravel Size in dtarnete <br />L Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter_ in ThiGmess/GaugefASTM Schell 1'1 Steel 11 Plastic i Stainless Steei r Other <br />Grout Seal Deplh ft 7 Neat Cement (94 Po bag/5-}0 gal waled D Sand Cement Sack mix.7 gal watt <br />Bentonile (20oA solids) : 1 Other <br />Grout Placement Method = Pumped D Free Fall C Other •J Retardant IAccelerator (name) <br />STAL Installed BY Driller ; i Pump Contractor n Other <br />Concrete Pedestal ... Dimensions: NMdlh fl Length ft Thick in ; I Christy Boz U Stove Pipe <br />W U SubmersiNellli'Turbene a Other HP Pump Sel ft Standing Water Level ry <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOACIUIN COUNTY ORDINANCES, STATE MWS, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT i AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />24 H D NCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 63- 97 <br />Tn Corp Secretary DATE Q.•7 /7 <br />REC� VE <br />St 11 <br />yo�,n w1N r `N <br />S�E�tFiO EPAP-µE <br />Application Accepted Ely <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring lApection By <br />COM?AENTS Y Lk&K 1 <br />ARTMENT USE ONLY <br />Date q � Y - i / Area I Employee IDN <br />Date L SPECIAL W®II Permit <br />Date 0 ❑ WAIVER Received <br />Dat Constricted Well Depth h <br />/)D <br />PE <br />codes <br />SC Received <br />Into B <br />CheekW Amount <br />Cash Remitted <br />Date <br />I <br />Perm[V Invoiceyi WepIOtA <br />Service Re est 7l <br />430 <br />0S0 <br />11-77 <br />43eh 2 <br />WF -LL IPUNP PERMIT <br />L'd VL9£L8860Z out ejellia4 eouei/und eb9: 6 6 L � 80 deS <br />