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166 'IN ME : [ [ 6106 'L 'A 1V p� C <br /> 1 <br /> WELLIPUMP PERMIT r <br /> SAN JoAouiNCOUNTy ENVIROtd7.1ENTAL HEALTH DEPARTAENT 1868 EAST HAZELToN AvENUE-STOCKTON CA 95205-(209)46d 20 �' <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES T YEAR FROM DATE ISSUED <br /> lojADDREsa 15863 French Camp Rd p Q� , ipon <br /> CROSSSTREETMurphy RD APN 2_0�—08 O—2 3 PA4CELSMEP_LAwo USE APPUCATION# A <br /> (J19NER NAME Wen Chang Su PHol, 09-402-8656 N <br /> OYTNERADDRE3S4204 Paquerette CIr Cm/SrA,z,Modesto CA 95356 <br /> CONTRACTOR Purviance Drillers , Inc PHD,,, 209-887-3554 <br /> CONTRACTOR ADDRESS P O B o x 64 CmISTATEMP Linden ,C a 95236 <br /> SUBCONTRACTOR PHDNE <br /> SUBCONTRACTOR ADDRESS CITYISTATFfzp <br /> LICENSE IX- C-57 D C-61 D-09 ❑Other NuMeER 377923 ,,. ,,o,,;DATE 7/31 / 19 <br /> Dowsrc WELL SAMPLING:L General Mineral/Coliform Bacteria(4391) Dibromxhloropropane(4392)7 Arsenic(4393) <br /> INTENDED USE 0 Dcmeatic/Pnvate C ImgatioruAgriCU turel D Industrial E Waler Quaky Mornitoritg -1 Soil Sampt cigrCharactenz-ation <br /> U Public Water System A�a <br /> If cd1mrt lrvm Owner Wet,Sysren,.Name Conlan Nam or Phare Na D, �N <br /> TYPE OFWOAK D NewWdl D Replacement Well ❑Wel AlterationlModificatien fl Other <br /> L) o <br /> Monitoring Well ❑ <br /> s) #of vrells Soil Boring(s) R or aannQS O Geotechni:zd 9 f bongs <br /> C Cut-Of-Service Well D Out-Ot-Serrce Wgl Renewal u Crass-Connection Repair Y <br /> New Pump C Pump Replacement C Pump Repair I]Raise Well Casing9 20 <br /> WELL CONS TTtUCT1ON <br /> 19 <br /> Dliliing Method C Mud Rotary C Air Rotary []Auger ❑ Cable Tool n Push Point D Oliver JQU/N <br /> Proposed Wall Depth ft Fxcavatlon in diame!er ❑Open Bottom C. Gravel PaOk/Glavet Size 7'." <br /> M C U <br /> I O)VM N <br /> .3 Conductor Casing in diameter I Conductor Casing Doth `t FPgR �N'TWell Casing DtrmeYer_ in Thldmass/Gaug&ASTM Schod C Steel J Plastic �Stainless&t tel D Other <br /> GroutSeal Depthft D Neat Cement(9476 bagi5-10ga1 wafer) C Sand Cement sad mrx <br /> El Bentonite 1,209E 3011(13) G Other <br /> i <br /> Groul Placement Method 0 Pumped D Free Fall D Other G Retardant/Accelerator(name) <br /> PEDESTAL Installed By Dnller G PuTtp Contractor Other <br /> D Concrete Pedestal DDlrnensIons_VVdlh ft Length ttThick in D Christy Box ❑Stove Pipe <br /> PO •SubmeTsi6le❑Turbine ❑Other HP Pump Set ft Standing Water Level ft <br /> I <br /> HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JDAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS_ 1 ALSO CERTIFY THAT FAY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> RAIN �24OV CE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209}953-7697 <br /> ED TrrLE Corpor Sectary �� <br /> 1 i <br /> I <br /> I <br /> I <br /> I <br /> I <br /> IE PA TM ENT U E 3DNLY <br /> Application Accepted ey Dele q Ales _ Employee IDO <br /> Grout Inspection BV Date ❑ SPECIAL Well Peron t <br /> PumpInspectioney PA�ky�\N\ �U���C `� 'Date V l�t�I �L\_ ❑ WAIVER Received <br /> Soil Boring Inspection By Date Co nstructed Well Depth h <br /> COMMENTS <br /> PE SC Received Check#! Amount Date Perm IV Invoice# Wen IDU <br /> Codes Info Cash R e-miffed Service uest# <br /> ■ <br /> n ■ <br /> ESD T]-aC BIDt/7e //t�. Q/O 12 / 7-3 Y/3L?UMP PEJtMR ■■ <br /> /` /—lJY_ l/ ■ ■ <br /> ■ <br /> L'd bZSCZ2960Z GUS S.Iejji-IQ aouelAind eLt OL 66 LO A�mm 0 <br />