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° WDLL 1 YUNIF -FERMI I SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTHRTMENT 304 E WEBE 3"'FL-STOCKTON CA 95202 - (209)458-3420 EFUNDABLE PERMIT 11 CALL 209 953-7697 FOR INSPECTIONS 'EXPIRES 1 YEAR FRIGAI-DA ISSUED fi 52L4d T � Rr��n S'c��r� n -- CITY/ZIP JOB ADDRESS 1 y CROSS STREET S. Sargent Rd. APN 053-04Q-32 PARCEL SIZE ,.Cc,,3 OWNERNAME :Brian Colburn l" 1"06i)+ LL( _ _. _-- PHONE OWNER ADDRESS P• C• BOX 754 CITY/STATE/ZIP C 1 emen t S, Ca 95227 CONTRACTOR Purviance Drillers, Inc. PHONe209-887-3554 CONTRACTOR ADDRESS P.C•BOX 64 CITY/STATE/Zip Linden, Ca 95236 SUBCONTRACTOR PHONE s� 1 SUBCONTRACTOR ADDRESS CITY/STATE/ZIP ' LICENSE INC-57 ❑C-61 ❑D-09 ❑Other NUMBER-,L31 7 7 EXPIRATION DATE 1M 03 C GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE g Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization j ❑Public Water System If different from Owner: Waler System Name Contact Name or Phone Number C^ t TYPE OF WORK ]l New Well ❑Replacement Well -❑Well Alteration/Modification ❑Test Hole ❑Other - ❑Monitoring Well(s) num6erofwells ❑Soil Boring(s) number of borings ❑Geotechnical number of borings S ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal New Pump ❑Pump Replacement ❑Pump Repair 0 Cross-Connection Repair WELL CONSTRUCTION Drilling Method R Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other Proposed Well Depth 3 0 0 ft Excavation 14 _7 5 in diameter 0 Open Bottom ❑Gravel Pack 1 Gravel Size in diameter ❑Conductor Casing in diameter / Conductor Casing Depth ft p Well Casing Di Thickness/Gauge/ASTM Sched . 15 6 CASteel ❑Plastic ❑Stainless Steel ❑Other �- Grout Seal D pih 2 6 0 tt ❑Neat Cement(941h hub 15-10 gal water) X3 Sand Cement 10 . 5 suck mix 17 gal water ❑ tonne(20% lids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Grout Placement Method umped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other ❑Concrete Pedestal Dimensions: Width H Length ft Thick in ❑Christy Box ❑Stove Pipe PUMP 3J Submersible ❑Turbine ❑Other HP_j_5__ Pump Set ft Standing Water Level ft WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other Well Diameter in Total Depth til Depth to Water ft ❑Casing to be Perforated from ft to 5 Sealing Material ❑Neat Cement(94 lh hug/5-10 gal water) ❑Sand Cement sack rnix/7 gal water ❑Bentonite Pellets ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File _ ❑Specs Submitted Placement Method ❑Pumped ❑Free Fal l ❑Other 13 Complete with Mushroom Cap ft below grade ❑Complete to Existing Surface Pad 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH'ALL WORKERS COMPENSATION LAWS. N1MUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS St ED SGC/' TITLE Coporate Secretary_ DATE 4/7/03 Ll MEW7rn 1 Q N � A- FNI iGlV1SI0N M to _ _ nn�o�rr ..._ fF _ 'Application Accepte T6 � iDate '� 3 _ Area Employee ID#_ Grout In ecti D �a�v Il SPECIAL Wetl Permit Pump lnspecti B Date ' © WAIVER Received_ Destruction Inspection By Constructed Well Depth 't;(�:f —ft COMMENTS PE SC Amount Check#1 Received Date Permitl Invoice# Well ID# Codes Info Remitted as By Service Request# z�� 03 s 003338 a 0 SE 00 33 3 MASTER WATER WELL PERMIT