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ILLI 'ON--- W:6paA I;3;� <br />WELUPUMP PERM[T P <br />SAN JOAQuw COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1686 EAST HAzELTON AVENUE-STOCKTON CA SS205 - (2118) 4se3420 <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br />.losAwREsa �16�51 N Jack Tone Rd CrTYrz,P Stockton CA qSd-1s" n? <br />CROWSTMWT(ip/ w r heXl -' AtAPN 1631 90045 PARCFiStg �LANpUSEAPPucATTOW# p <br />Jose Monteen p <br />OWNER NAME �^ <br />PHONE � <br />DIVN ER ADDREss 1651 A Jack Tone Rd crimisTA1is7, Stockton, CA g i a J <br />:.ONTRACTOR Purviancd Drillers, Inc PHONE 209-887-3554 <br />:oNTRAC roR ADDRess P O B o x 6 4 CITY/STAT-0P Linden , C a 95236 <br />SUBCONTRACTOR ADDRESS <br />IICIENSE t3 CG 0 C-61 ❑ D-09 ❑ <br />CITY/STAWJZW <br />NUMBER 377923 <br />PHONE <br />EXPIRATION DATE 7/ 3 1/ 19 <br />DOMESTIC WELL 7 General MlneraUCorWrm Bacteria (4391) = Dibrotnochloropropane (4392) Z Arsenic (4393) <br />iHTENDED Ust_ 0 ❑omestic/Private 41 InigavOWAgricutural D industrial D Water Quality Monkoring 17 Soil Sampling/CharecierUstlon <br />0 Public Teter System <br />Ifatieznl Yom Own er Water yslem Neme Conted Name or Phone Number <br />TYPE OF WORK 1111I New Well 0 Replacement Well 0 Well AlloratitxNModification D Other <br />❑ Monitoring Welds) #dwells G Soil Borings) sorbonnps 0 Geotechnical <br />2 Out-Of-SerAce Well 0 Out-0rSemce Weil Renewal 0 Crow -Connection R—ir <br />a <br />u or bonnas <br />Drilling Method • Mud Rotary ❑ Air Rotary D Auger/ O Cable Tool ❑ Push Point CI Other <br />Proposed Well Depth 350 ft Excavation 1 4 3114 in diameter 4p Open Bottom G Grave! Pack/Gravel Size in diameter <br />D Conductor y jy/A in diameter / Conductor Casing Depth ft <br />mm <br />Well Casing Diameter 7 T IcknessfGaugelASTM Schad _!g% 9 Steel 0 Plastic D Stainless Steel U Other <br />Grout Seal Depth / -I-- ft C Neat Cement (44 lb bSaW5.10 go( water) ti Sand Cement / O. 3 Sack r dJ7 gal water <br />0 Bentonite(20%solids) 9 Other <br />Grout Placement Method IF Pumped ❑ Free Fall 0 Other ❑ Retardant/Accelerator (name) <br />.rra—KrU Dy to unser 0 Pump Contractor ❑ Other <br />n Concrete Pedestal 00imensioas: VMM R Length ft Thick in 0 Christy Box O Stove Pipe <br />PUMP D SubrnersibleO Turbine 0 Other HP Pump Sel ft Standnlg Water Level fI <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 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 />WOR ENSATIONLA <br />MINFIN 2A HO VA CE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 95 -7697 <br />SIGNED <- TITUCorpor Sectary OAT. 2 20/17 <br />©�` '�UrN OUtiN D, ARTMENT USE NLY <br />�.M4RTME9Wppligtion Accepted By 14a, DeleArea Employee ID✓J,� <br />Grout Inspection By u Aate 0 SPECIAL W911 Perrnit <br />Pump inspection By Date 0 WAIVER Received <br />Sol Boring Insptecllor By Date Constructed Well Depth It <br />COMMENTS _ r tc.L-k- <br />W QS rz� oa <br />WELL !PUMP PFRWT <br />EIVE® <br />21 2017 <br />HEAitTH <br />,V'd - LZSU2260Z out sae�Ei14 eoueyund 060:06 LL LZo;,�G <br />k <br />MAMM <br />�i�i�i■ii�ii <br />��� <br />WELL !PUMP PFRWT <br />EIVE® <br />21 2017 <br />HEAitTH <br />,V'd - LZSU2260Z out sae�Ei14 eoueyund 060:06 LL LZo;,�G <br />k <br />