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9H11 "N AHS :b L10Z 9Z •I11 ?UIl PaA1 0 <br /> WELLIPUMP PERMIT P <br /> SAN.IOAOULN COUNTY ENVIROPWimTAL HEALTH DEPARTVENT 1E69 EAST HAgiTON AVENUE-STOCKTON CA 135205-(209)4683420 V� <br /> INON-REFUNDABLE PERMIJ CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FRom DATE ISSUED <br /> iJOB ADDRESS 16360' Fox Rd C,,zlLodi CA 95240 m <br /> ICRoss STREET H Q Y " AP O PARCELS2Ej / LIWDUSEAPPLICATTCNP <br /> IOvrveRNAti+E Angelo Caffesse >f�V� ._I(,I ,.� _ p1Cie209-200-2264 <br /> �D;•,NFR ADDRESS 16 3 6 0 Fox Rd T7TTCn Y>STATErZ L o d i ca-95240 <br /> 1COmTRACT1DR Purviance Drillers, Inc_ _ 2n9-887-3554 <br /> CON1R4CiT:R ADDRESS p- 0. RoX 64 CITWSTATE(LIP Linden, CD, 8523 <br /> SUBCONTRACTOR PHONE <br /> li <br /> SUBCOX-RAC7CR A70R:S5 Cm'fsTATEfzrp <br /> LlcExsE Jt!Gs _'C•61 0-09 :Olhe.- NUMBER 377923 E.l......N DATE 7/31 /1 Z7J <br /> GECORAPIL'CALINFORf,IAtIM'l: Coordinalesx Y Tawnstup_ Range Section_ <br /> LM 794 0--T)USE -Oomestic/Privale LTngatiorVAgTioillural '_Induslrtal =Water puafity Uoniloring Sml 5ampfrn9lCharerSruila6on <br /> Public Water System <br /> if tliP,ertm hom Ounor +cr ys em. .c �`nrione <br /> IYFEOPVJORK Neu Well _ .Replacement Wel . WOR AlteratiON&I065COL'on Other <br /> -Monilcring WLI1(s) t,-of,,,Vls ::Sof.Bonin s pormrir awb.;-V <br /> 9I) Geotechnical 77 x, rT <br /> -Out-O(-Service Weal 00-Or-Service Well Renerel 7!C(OSS-Connection Repair ZNew /w` <br /> ew Pump m m <br /> Re !aceenl C Pum Repair _Raise WeA Caslnq__""_ { , <br /> WELL CONSTRUCTTON —� ` i <br /> r. <br /> Drilling Hethod Mud Rotar}' _ Air Rotary -. Auger _ Cabie Tool _Push Point _ Other I 2Ts�1 <br /> IPr000sed Well L`epth ft Exrawkon in diameter _ Open Bali 7 Gra-.e;PacWGrauel Size !.n dsmelerl ^ M <br /> ConducO-Casing indta,Teier / Conductor Casing Depth <br /> Well Casing Diameter_in ThicknrsJGauge)AST,,A Sched : Steel u Plastic _ Stainless Steri -1 GYher <br /> I Grout Seal Depth ft 'Neat Celrtent(94 lb bag'STOgaf Aet fj S d Cement sa k mixt gal wales <br /> Bentonile J20%solids,' :Olhe�- <br /> Grout Placernen[M1}ethod -pumped free Fall -Other "Retardant/Acceerat or(name) <br /> PEDESTAL Installed BY Driller Pump Ccntraclor Other <br /> _ Concrete Pedestal _Dimenslons.'Ndth R Length It ThICk in L Christy Hor Stove Pipv <br /> (PUtAP APSubmersiDlw.Turbine Other HP Pump SP1 Fl Standing VdalcrLew_I it <br /> I HERESY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WIL. BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT ray REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORA9A CONTRACTORS STATE LICENSE BOARD AND THAT i AM IN COMPLIANCE WITH ALL <br /> 'NOR" NSATION <br /> MINI 24 ANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SlGVED -.�-��'�zcc T,,1, Corporate Secret c,/- 7-/ <br /> 1 1 1 LL <br /> t - i <br /> - -- <br /> I <br /> I - I <br /> � p <br /> 1 � <br /> OR���� . <br /> i IA rji� 4-11 JOA <br /> I <br /> E P R T M ENWTU E N LYApplrralian Accepted By Date Area Emp oyee 10r,_�• '•�v <br /> Groul Inspection By tete 7 SPECIAL Well Permit <br /> Pump Inspection By Dete 2 WAIVER Received <br /> Sal Scring Inspection By Date Constructed Well Depth l <br /> COMMENTS <br /> IPE SC Received Check*/ Arnount Date Permitl tmoice# I WeI11IXt <br /> Codes Into B Cash Remitted Service RequestV <br /> JOU•+^G � � .JILIPU LI>PER`J:T <br /> Inc l� l✓�� ���5� <br /> t Innr_n� nlll clanlln anIlvlAln-j cit c'1 1 70+,7 A0N1 <br />