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E[I "N WdLZ :ti L10Z I n aalil paAiaaa� <br /> ' WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1 B6B EAST HAZELTON AVENUE-STOCKTON CA S5205.(209)"S-3420 <br /> NON-REFUNDABLE PERMIT CALL 209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOBADDRESS 9688 IOakwilde Ave _ cIIStockton , CA 9SZ/Z <br /> CROSS STREET t. �//�{ O <br /> _ APN R rL Sri LAND UsE APPUCAT7ON# a <br /> OWNERNAME Sam Orlandoll PHoNE916-708-4999 <br /> OWNER ADDRESS <br /> 9688- O a k w i l d.e Ave e CITY/STATTJZlP Stockton, CA <br /> CONTRACTOR Purviance_ Drillers , Inc PHONE209-887-3554 <br /> CONTRACTOR ADDRESS P . O. Box 64 CITYISTAmZlP Linden , CA 95236 <br /> I <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADORE3S CITYISTATEIZJP <br /> LICENSE T G57 G67 L 0-09 Outer Will EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates Y Township_ Range Section_ <br /> INTENDED Uar dDamesticJPnvate L Irrigation/Agricultural ',]Industrial 7 Water OualityMonitoring ❑Soil Sampling/Characlenzation <br /> _Public Water System <br /> Ir direreN Dom Owner. er I'°m Nam. on arta or .one mn er <br /> TYPE OE Wolac 0 New Well :. Replacement Well L;Well WteralioNModifigtion Li Other <br /> r Monitoring Well(s) #of wells rI Soil Bonng(s) Y w bonnss r Gectechnical a°r 4°ntis <br /> I_I Out-0fService Well .-7 Out-Of-Service Well Renewal !'CrossCcnneclion Repair^3- <br /> rt New Pump C Pump Reploolernerd r]Pump Repair !'Raise Well Casn <br /> WILL CONSTRUCTION <br /> 'Or)itireg Method rj Mud Rotary . Air Rotary I Auger ; Cable Told _I Push Point = Other <br /> Proposed Well Depth AfO R Excavation in diameter 111"Open Boltom a Gravel PacklGravell Size in dameter <br /> Coinductor Casing in dfameler / Conductor Capsing Depth R <br /> WeII Casing Diameter in ness/GaugeJASTM Sched P/td R Steel Plastic Seamless Steel !7 011ier <br /> Grout Seat Depth �(7 L ) Neat Cement(941b bag15.10gaf water) 4Sand Cement /I sack mfx/7 gal water <br /> 7.Bentonile(20%solids) Other <br /> Grout Placement Method$rPumped _Free Fall Fl Omer Retardant 1 Accelerator(name) <br /> PEDESTAL Installed By -Driller i Pump Crnbaclor G Other <br /> I.!Concrete Pedestal_Dimensions.VJdth ft Length N ThiCk in I Christy Box Stove Pipe <br /> Pl1tdP I.I Submersbteu Turbine Other HP Pump Set it Standing Water Level fl <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> IMUIUI 2 ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 f <br /> SIGNZ4 <br /> s�cc TITLECorp Secretary DA„$/17/17 f <br /> I <br /> - � m <br /> i - 0 <br /> I IL 1. 11 <br /> L '? M <br /> YMENT I I = p <br /> R al <br /> RECEIV E) <br /> A� 2Z2 <br /> GOUHN PA TMENT E O L <br /> SAN JOAQUI'N AL <br /> E TMRDEPp MEI-A'ppI cation Accepted By to � � Area � Employee ID#_�"� <br /> NEAT Grout Inspection 1V leD PECIAL V II Permit <br /> Pump Inspection By Date_ ❑ WAIVER Received l� 1 <br /> Sol Boring Inspection By Date nsuucted Well Depth U d tt <br /> COMMENTS <br /> PE SC Received Chelew Amount Date Perrniv Invoice WelllD# <br /> Codes o Cash Remitted Service Re uest# <br /> 6H043-0e <br /> crlen2 ��� O 7 2.z 1`JJ\_ WELL,PUN•P=RMIT <br /> Z-d VZSCZ2960Z out sjejju4 eoueiAjnd dtZ:to L l L l f)nV <br />