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`WELL I PUMP PERMIT N D, <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DTMENTxo <br /> 304 E WEBER 3 FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> LA <br /> JOB ADDRESS 144n4 E Hwy 26 CITY/ZIP Linden, 95236 <br /> M <br /> /� n(,�//� a <br /> CROSS STREET Jack Tone APN l ~tJ�'t✓A PARCEL SIZE �LAND USE APPLICATION# <br /> OWNER NAME Carl Grupe Ranch PHONE <br /> OWNER ADDRESS 14404 E Hwy 26 CITY/STATE/ZIP Linden, Ca , 95235 <br /> CONTRACTOR Purviance drillers Inc PHONE 209) 887-35-54 <br /> CONTRACTOR ADDRESS 17707 E Hwy 26 CITY/STATE/ZIP Linden, Ca. 95236 <br /> -- <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE MC-57 ❑C-61 ❑D-09 Cl Other NUMBER 377923 EXPIRATION DATE 0 7—31 -0 7 <br /> GEOGRAPHICAL INFORMATION. COOrdinBtes X Y - Township Range Sectio. <br /> [NTENDED USE Cl Domestic/Private IR Irrigation/Agricultural ❑Industrial '❑Water Quality Monitoring ❑Soil Sampiing/Charactcrization i <br /> ❑Public Water System <br /> If different from Owner: Water 9yStem <br /> Name-Contact Name or Phone Number <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> ❑Monitoring Well(s) #of wells ❑Soil Boring(s) N ofbonngs ❑Geotechnical u of borings <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> 1 ❑New Pump q Pump Replacement ❑Pump Repair <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other j <br /> Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth' ft j <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other { <br /> Grout Seal Depth ft ❑Neat Cement(94 th bag 15-10 gat water) ❑Sand Cement sack mix L7 gal water . 1 <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted I <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP ❑Submersible Turbine ❑Other 'HP - 60 Pump Set 16 0 ft Standing Water Level ft <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. 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 /> UNI 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNS TITLE Corporate Secretary DATE 6/26/06 <br /> k <br /> s <br /> i <br /> j� <br /> I <br /> L t:1 V _I _I <br /> 9 <br /> ; <br /> S N G. ; Ir r 1 <br /> EIIVljl(� IV,E NT al'- <br /> p, -71V E r <br /> t <br /> . WE A R4T M E'N T S r N <br /> Application Accepted By t "Date Area ~� Employee[D#'' <br /> Grout-Inspection By //" Date 0 SPECIAL Well Permit <br /> Pump Inspection By z("'tt '� Date A /52C `❑ WAIVER Received % <br /> Constructed Well Depth ft <br /> COMMENTS <br /> -PE SC Received Cheek#! Amount ,� Permit/ <br /> Date Invoice# We1LlD#. <br /> Codes "Info By ra-sy- Remitted Service Request#- - <br /> tr-- b zfi SFS 5 �.� . Z <br /> EHD 43-02-006 <br /> 1/27/2005 WELL PUMP PERMIT <br />