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Apl- 22 01 11:45p <br />1 <br />WELL/PUMP PERMIT <br />SA.V JoAOU1N COUNTY EwwoPIMENTAL HEALTH DEPARTMENT 1868 EASTHAo--ELTON AVENUE- STTv--. r a oc�nc <br />N <br />CALL (209) 953-7697 FOR <br />1 YEAR FROM DATE <br />ADDRESS U21 N RPPr'her RT) cnYrapStockton 95215 <br />93 STREET-.— COdTiStOCk Rd APNOR91 401 2 PARGELSIZE b• LAND USE APPUCATON fJ: <br />IEA NAME Frank Stonebarger PH0NE209-401-6790 <br />iER ADDRESS 8408 N Beecher C1Tr/STATEiZIP S t oc k t on 9 5 21 5 <br />TRAMOR Purviance Drillers,Inc PHoN2-09-A 87-3554 <br />TRACTOR ADDREW a- O. 13ox 64 CrTYISTA-temp Linden, Czk 95236 <br />:ONTRACTOR PWOME <br />SUBCONTRACTOR ADDRESS <br />LICENSE XC -57 a C-61 u D49 2 Other- <br />CnYIS TATEIZIP. <br />NUMBER 377923 <br />EYPrRATION DATE 7/31 / 17 <br />...,.R.A..-.rYFU-TtoN: t:oorornates x Y —Township_ Range Section_ <br />NTl3VDGDUSE C <br />IDomestic/Private InigatiorJAgricultural O Industrial 11 Water Quality Monitoring ',Li Sal SamplinglCheracberizaBon <br />u Public Water System <br />If 417e 14 ficin Owner. vvaftrziyslem r4a t o amo er mxr <br />TYPE Or WORK ' t New Well L Replacement Well !.j Well AReration/ModiGration U Other <br />fn Monitoring Well(s) a of wells i-; Sail Boring(s) °,food,." C Geotechnical <br />Out -Of -Service Well - Out-OfServtce Well Renewal Cross -Connection R�I�y�r !' <br />New Pump C Pump Replacement - PUmD Repair r 0�. - IAI-e n—:— <br />Drilling <br />—:— <br />Drill i n Method 'moi f ■ <br />9 •Mud Rotary L A1rRotary �AugeryL Cable ;Push Pant tV Other i� <br />Proposed Well Depth ( _h F_xcava1104 q{ !"— in diameter S Open Bottom _I Gravel PacIdGrevel Sze in diameter <br />Conduct% i g in diameter / GOWUCODr Casing Depth fl <br />Well Casing Diametef174in ThidmessrGaugafASTM Schad 6 Steel ❑ Plastic C Stainless Steel i Other <br />GroutSeal Depthg3b R C Neat Cement (94 lbbag^S-10 gat water) 0 Sand Carnent /O• C- satyr nW7gal water <br />n Bentonite (20% solids) ,-I Olher <br />Grout Placement Method Ir Pumped 7 Free Fall _ 0 Other C Reterdanl /Accelerator (name) <br />PEDESTAL InstAled By ❑ Driller ump Contractor 17 Other <br />T ncrata Pedestal, ensions V r= ft Length ftThick in Li Christy Box U Stave Pipe <br />R' RNIt !. ubmersib6eu Turbine i.! Other HP Pump Set ft Standing Water Level tt <br />1 I HEREWj§AT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />�� NANCES, STATE LAWS, AND RULES AND REGULATIONS- 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />E WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br />ONSATION LAWS- <br />RECE <br />OCT q <br />SAN JOAQ <br />EW1RC <br />HEALTH C <br />Application Accepted By <br />Grout Inspeaon By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />TITLE Corporate SecretaxAy 9--,i/-./,s- <br />DEPARTMENT USE <br />--,i/is- <br />DEPARTMENTUSE ON,LLY <br />Data <br />Dale <br />Date <br />Date <br />p.3 <br />ra <br />D <br />e <br />A <br />m <br />Area 041 l E-ployee IDR (,-7'J&2P <br />SPECIAL Well Permit , <br />❑ WAIVER Received <br />Constructed Well Depth it <br />PE SC <br />Codes Into <br />Received C <br />B Cash <br />Amount <br />Remitted <br />Data <br />PenniV <br />Servicer Request* Invoice 1 <br />qFy <br />3`kl <br />s r <br />S2oa73-'I9 JL ll-:Jx%lvxjxL <br />Arnim <br />-ir. <br />EMO 4] <br />4n&112 <br />Received Time Sep,23, 2015 4:19PM No -96308 <br />WELL IPUTAP PERUFT <br />lel <br />t <br />