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FECE <br />APR 2 3 <br />90 E "N W E: E 8l0Z 'EZ ') dy aul I1 1);A I; <br />L.t�� VVELLIPUMP PERMIT <br />SAN JO— COUNTYENMONMWAL HEALTH DEPARrmENT 1868 EISTHAZEL— AVE NDF-STOCKTON CA 95205 - (209)45$-3420 <br />IWKEFUNDABLE YER_MIT L;ALL ZU9 953-7697 FORINSPECTIONS EXPIRES 1 YEAR FROM )TATE ISS <br />Aoo� 3/�r N Jack Tone Rd ,,,,,Stockton CA <br />SSSrREEr f�flll/ APN 105-07e`Oi' PARCELsu26 - Us APPItcAnON <br />N.,w Vernon G Go na Partners h.i Vi�09-603-0011 <br />AacnE3s'13959 E Fannin Rd ,c,,,,sTA,Frz$tockton CA 95215 <br />CTOR Purviance Drillers, Inc PMONE 209-887-3554 <br />crOR AD D1tEss PO Box 64 CMISTATMPL i n d e n, C A 95236 <br />IMCTCR F41MM <br />CST a C-51 D 0A9 0 <br />Ndmsm <br />C1TWSTATEl1[P <br />DOMEsTrc WE LLSANPLu4a: a General MineraXaffform Bacteria (4391) - Dibromochloropropane, (4392) Arsenic (4393) <br />WIENDE D UrE D OamestImPrivate Irrigaiion/Agdcullural C Industrial C VVaterQuaGty MDnRo vig O Sail SarnplingrCharecteri2stion <br />C1 Public Water System <br />EfIftrart Win Qwaer. Yheersystvn Naas Ccram7 Namt or Phone Number <br />TVPEOFWORK D New Well C Replacement Well C WetlAlteratioNNlodificiticn 0 Otter <br />D Monflotrtgwell(s) aofWeft G SZ11aaring(s) earear"s 0 Geotechnical 0ofborugr <br />0 Qut-OfService Well C Out -Or -Seri ce Weil Renewal C Cross-Cannedian Repair a' <br />Ortlllng Mediad O Mud Rcmry C Air Rotary D Auger ❑ Cable Tool D Push Point D Other <br />Prop DsW Well Depth_n Excavation in diameter -' Open Bottom O Gravel PaWGrays: Size in diameter <br />ConduclorCasing in diameter / ConduclorCasing Depth R <br />Well Casing OlameW _ in -Ih!dmessfGaugelASTM Schell C Steel O Plastic D Stainless Steel 0 Other <br />Grout Seal Depth_ft D Neat Cement (941b b39l54Cge1 oraeed 7 Sand Cernent sack ffW7 gal ureter <br />D Benlonite(2O%solids) ❑ Other <br />Grout Placement Mathod D Rzmped 11 Free Fall D Other G Retardant /Acmlmtar (name) <br />IZE—DEsTAL Installed By 12 Ddler C Pump Contrador 0 Other <br />DCon enetePedestal DDlmenstons: Vl�dlh ft Length RTtridt In DChristy Box !'I SlavePfpe <br />_runrr u auDmmsolepr IVrnine J Vtner HP VJv PUMPSeL—J 0% ­'—ft StandingVVHlerLevel-f-Z:YIll <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND PULPS AND REGULATIONS. 1 ALSO CER71FY THAT MY REQUIRED IJCENSE IS � <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE UCENSE BOARD AND THAT 1 AM IN COMPLIANCE WfTH ALL <br />WORKERS COMPENSATION LAWS. <br />R71 UM 2 VANCE,NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (249) 953-7697 <br />SIGN w%- TOrpOrate SeCret8l'$ATE73 /g <br />Application Accepted By <br />Grout Inspection By <br />Pomp Inspection By <br />Sail Boring Inspection By <br />COMMENTS <br />�P RTMENT JLIAE <br />D LY <br />Date / .MeaEmployee I <br />*0PEclellDate Parmlt M663� <br />Datei4tifb O WAIVER Received <br />Date Constructed Well Depth It <br />aDaaae mine <br />Z•d <br />tZ9£L8860Z <br />C'� X 777,,-7,��8- <br />W'3L17UMPPEMVr <br />CA <br />T. <br />a <br />a <br />9 <br />Y�'FNr <br />242018 <br />/M N0*NrY <br />OU1 S.IaIII.IQ aoueiAind d9Z:£0 9L £Z AV <br />