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6titiPIN Wd : k U06 U 'ldV said paAI ;D9� <br /> t WELL1PUMP PERMIT v <br /> SAW JOAQUIN COurdTyENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAzELTONAvewlS-STOCKTON CA 95205-(209)4683420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joe ADDRESS <br /> 21081 Tiwy 26 CnY/Z1P Linden , CA 952m <br /> n a <br /> CROSSSTREET 691��/ APN (��'� PARCELSIZE�LAND USE APPLICATPON a S <br /> OWNER NAME Mike Pe]-barn PIII.E209-4 32-6166 <br /> OWNER ADDRESS P 0?3 o z., 12 6 0 4 Cmr1STATFJad--'i n d e x, CA 95236 <br /> CONTRACT, Purviance 'Drillers , Inc PHONE 209-887-3554 <br /> CONTRACTOR ADDRESS PO Box 64 CrnNSTATE*ZJPL i n d e n, CA 95236 <br /> SUBCCNTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATEJZIP <br /> LICENSE T,C-57 U C-61 D D-09 D Other NumeER 377923 ExPiRATHm DATE 7/31 /19 ' <br /> DCMESIIC WELL SAMPLING=:7 General Mineral/Coliform Bacteria(4391)-Dibfomochloropropane(4392)=Arsenic(4393) �� <br /> INTENDED Use JI('bOmesticJPrivate 0 Irrigation/Agricultural 0 Industrial O Water Quality Monitoring 0 Sa8 SamplinglCharactenzation/7PubSc vYste System �elcrdrrareW rmm Owner. VJatefSyslnm Neme Cml ea Nerf or Ph—Number ED <br /> TYPEOFWORK D Mew Well C Replacement Well 0 Well MeratiorUModilicaticvl D Other ;i <br /> C hPoniloring Well(s) #ofwells r:'W Boring(s) aofboaogs 0 Geotechnical Alcfbcrings r 'l <br /> U Out-Of-Servlae Well C Out-Of-Service Well Renewal 0 Cross-Connection Repair ,�+��, G 018 <br /> D New Pum um R lacemeat C Pum Repair ❑Raise Well Casing8AWNJO <br /> ZStuc'nON �Q� U(N OOUN7�d O Mud Rotary O Air Rotary D Auger 0 Cable Tool 0 Push Point © Other h "N NMENT 7rl Depth ft Excavation in diameter C Open Bottom ❑Gravel Pack/Gravel Size in diameter EPART NT <br /> n Conductor Casing in diameter I Conductor Casing Depth k <br /> Well Casing Dlameier_in ThicknesslGauge/ASTM Sched L: Steel G Plastic ❑Stainless Steel D Other <br /> Grout Seal Depth ft D Neat Cement(941bbag'SfOgal veter} C Sand Cement _sack nzxl7gal water <br /> Bentonile(20!solids) 0 Other <br /> Grout Placement Method C Pumped D Free Fag ❑Other Retardant I Accelerator(name) <br /> PEDESTAL Installed By D Driller 0 Pump Contractor ❑ Other <br /> 0 C one rate Pedestal O Dimensions:Width ft Length ft Thick ir, 0 Christy Bax 0 Stove Pipo <br /> PUMP SubrtlersiNe❑Turbine ❑Other. HP_L-L_ Pump S ft Standing Water Level ft <br /> t 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 t AM IN COMPLIANCE WITH ALL <br /> WO MPENSATION LA <br /> MINI UM 24 ISO //- CE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED �. �" � orporate Secretar&,= 7-/,11 <br /> i <br /> EIVkj) <br /> 1 A .1 1 1 <br /> j272018 <br /> ER���TK <br /> E <br /> E <br /> PA TMENT U E ONLY <br /> Application Accepted By Dale Area Employee IITEt <br /> Gran Inspectierl By <br /> Dete 7 SPECIAL Well Permit <br /> Pump Inspection By _ r Date Cl WAIVER Rece(ved <br /> Soil Boring Inspection By Date VV Constructed Well Depth R <br /> COMMENTS <br /> PE SC Received Check* I Amount Date Permltl Invoke Well ON <br /> Codes Info h Remitted Service Re user# <br /> a <br /> EH047-OS 641119 /7 73 <br /> 1VELL IPUPIPPE-IMR <br /> £'d VL9CZ2260Z 01-11 S1811!J(]aoUeiAind ?/Z:L L 9 LZ add <br />