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E8S1 'ON AVE: h NH '9Z 'ASA ;W11 paA l;);� � <br />WELUPUfWP PERMIT <br />SAN JOAQL*4 COUNTY E!NiRONMENTAL HEALTH D EPARTNENT t B6B EAST HAM -ION AVENUE- STOCKTON CA SS205 - (M) 468 -342C <br />IV VN-KEFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUEL <br />JOB ADDRESS 13845 E Live Oak Rd C,TT,2PLodi CA 95240 <br />CROSS sTREET J a c k T o n e Rd APN PARCEL SOF J' ( It �I,AAi0 USE APPUCATION ft <br />DInNERNAME Mark Tanner PHoAE209-410-8627 <br />OWNER A....13845 E Live O a k RD CnYfsTATuaL o d i CA 95240 <br />CONTRACTOR Purviance Drillers, Inc. PHONE 209-887-3554 <br />CONTRACTOR ADDRESS P. 0. Ro x 64 cmr,STAT9Zy-_ - Linden, CA 9 5 2-31 <br />CDYTRACTCR <br />SUBCONTRACTOR ADDRESS <br />UcEmsE L G57 _ C•61 i D-09 <br />CrTY1STATE/LP <br />Other NDl aER 377923 <br />PHOME <br />EMRATION DATE 7/31/17 <br />GEOORAPFRCAL INFDRNIA71ON: Coordinates X Y Township_ Range Section_ <br />INTENDED UsE 40 DOmestidiorivate irrigatiorVAgdcullural U Industrial = Water Quality Monitodng ^_ Soll SamplingXharactetiranon <br />PuNic Water System <br />It dflMnl from C" AE . - Y. em a pe <br />TYPE OF WORK _ New Well " Replacement Well Weil AllerationlMOdification _ Other <br />-. Monitoring Well(s) 9ofv&ls :! SoitBoring(s) --.1 D 4p 7 Gectechnirai Pa1°0n"� <br />Out-Of-Servica WW - Ori-Of-Servioe W0Reneval :? Cross -Connection Repair <br />New Pump &Purnp Replacement d; Purn2 Repair Raise Weil Casing <br />WELL CONS-MUCTION <br />Drilling Method _ Mud Rotary Air Rotary . Auger Cable Tool ! Push Point _ Other <br />(Proposed Well Dep117 ft Excavation in diameler Open Bottom Z Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter 1 Conductor Casing Depth ft <br />Well Casing Diameter_ in Thidtness/GaugeIASTM Sched Steel Plastic ' Stairdess Steel :2 Other <br />Grout Seal Depth ll Neat Cement (94/D l W-1-10ga/ realer) Sand Cement sack m&J7 gal water <br />- BerAcnne(201. solids) : Other <br />Grout Placement Method _Pumped Free Fall =Other Retardant IAcceleratdr(name) <br />PEDESTAL installed Hy Dnuer Pump Con"Clor Other <br />Concrete Pedestal:.G7mensions:Width 0 LenUU1 nTtvdc__ in �CbristvBox LStove Pfoe <br />,PUMP M Suhmersible� Turbine :;Other_ HP ­'_-_ Pwnp Set Z��ft Standing Vlhdef Level / it <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL eE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I 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 />WOR7'�WCN�IM,:2�,.Ko#*ANCE <br />ENSATION <br />NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209) 953-7697 <br />0) <br />D <br />d <br />v <br />DE ARTMENT USE ONLY <br />App)'Kation Accepted By Date Area GY7 "L I Employee II - L i <br />Grout Inspection By Date Di SPECIAL Weil Permit 4 <br />Pump Inspection By pate I % D WANER Received <br />Soil Boring Inspection ByDate Constructed Well Depth h <br />COMh1EN1T5J� �'��,� �` 1� qI -T/,„ <br />PE SC Received Checkk! <br />Codes info 8 Cash <br />Amount Dare <br />Remitted <br />PertaN Invoice# <br />ervice Re vest it <br />WelllD# <br />72.s <br />I vis <br />T1� 1 ,1 <br />0-d t Z99L9960Z <br />'.VM-L/PURtP PEgwT <br />out Saa11iaQ aoueiAAnd e0£; L L L L 9Z AeW <br />