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0y,,^ 9690 'ON AW : 6 LIH 'Ll 'upr ;trill paAI ;3;� <br /> WELUPUMP PERMIT (� <br /> SPN JOROUW COUNTY ENV:RO NMENTAL HEALTH DEPARTM-ENT 166S EAST HA2ELTOM AVENUE-STOCKTON CA 95705-4209)468-.3420 <br /> NON-REFUNDABLE PERMIT CALL 209)953-7697 FOR INSPECTIONS EXPIRES'I YEAR FROM DATE ISSUED <br /> N <br /> JoeAODRess 6250T�TEscalon Belo2tta Rn �,TM�,PLInden CA 95236 m <br /> GROSS STREETF f o o d R I) APN Ljo-a PARCEL S / D(JSE APPLICA ION C m <br /> 3OWNER NAIVE G HO„0 9—8 8 7— 0 2 5 <br /> try_— <br /> OWNER ADDRESS 4 —t a �f I�7U � O�TY! TATFJ7JP <br /> Purviance Drillers Inc. 209-887-3554 <br /> CONTP-C cmR 0 PHONE <br /> i CONTRACTORADDREss P- 0. T3oX 64 CIMSTATsMp Tinden, C4 95573 <br /> SUBGOMRACTLIR PHONESURCONrRACTOR A00REss C[TYlSTATEIZIP <br /> 377923 7/31 /17 <br /> ILIcFNSE C-57 G61 I D-09 Other NUMBER ExP1RATION DATE <br /> GEOGRAPHICAL INFORMATIOW Coordinates X Y Township_ Range Section_ <br /> INTENDED UsE DomestiUPr[vate M ImgationiAghcuttural C Industrial 7 Water Quality Monitoring -Sod Sarnpling)Characterization <br /> . Puhl:c'AlalerSystem <br /> 11d,91mn1fmm Owner (;—[.1A Na or ne N.mx, <br /> TYPE OF WORK _NevrWell _ Replacement Well _i Well,WerationWodifiralion Other <br /> Monitoring Wetl(S) ,of yells 11 Soil Borings) Potborings _Geo•echn)cal Gof CerhNs <br /> -1 Oul-Cf-Service Well _ Out-Of-Sendce Wei[Renewal Cross-Connection Repair <br /> J New PUmD Pump Replacernent !:;Pump Repair Raise Well Casino <br /> WELLCONSTRUCTION <br /> r Drilling Method Mud Rotary _Air Rotary --Auger Cable Tool _Push Poirt _ Other <br /> Proposed Wel[ Depth ft Excavation In diameter Open Bottom =Gravel PactdGravet Size in diameter <br /> j _Conductor Casing h diameter I Conductor Casing Depth ft <br /> Wel l Casing Diameter_in Thiccrne,%OGaugedASTA7 Schell I;Sleet --Plastic _Stainless Steel _Other <br /> j Grout Seat Depth ft C Neal Cement(941b bagrS-10 gal wa(er) _Sand Cement sacif mixR gal crater <br /> -Bentonite(20%solids) Olher <br /> Grout Placement Method �Pumped Free Fall -Other L.Retardent/Accelerator(name) <br /> PEDESTAL Installed By _Driller =Purnp Contractor - Other <br /> I I_Concrete Pedestal—Dim;nsion6:'Arodlh it Length fl Thiel; in Christy Box -Stove Ripe <br /> �Putaa -_Submersible ifTurNne �..Olher HP -2> Pump Set �. ft StandingWater Levei /ST Il PAY <br /> OA COUNTY UNNTY ORNANCES, STATE LAWS, AND RULES AND REGULATIONS.I HERESY CEFMFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE W 1ACCORDANCE <br /> ALSO CERTIFY THAT MLL BE DONE IN RE1 <br /> UIREDLIC <br /> TH SAN Arr <br /> , ENSE IS <br /> CURRENT AND ACTIVE WITH TKFCALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN CONIPUA14CE WITH ALL <br /> WORK NSATIONPAUS, <br /> iV11NMAU 24 H NCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(204)953-7697 1 8 41.71 <br /> S1ONE0 TIDE Corporate Secre Li r Z / <br /> A au <br /> mk <br /> 7 <br /> I i II <br /> i I I <br /> I <br /> 3in E <br /> I `QED <br /> _ ? I <br /> i I <br /> I --' 2014 <br /> II 1 1 2 1 hu 04TAL MI <br /> a i r <br /> I <br /> iI <br /> I I ' <br /> I <br /> I I <br /> EP RTM ENT ENLYApplication Accepted By DattS <br /> F�2a_!C� Employee IDN <br /> Grout Inspection By Date II �, � PEQAL Well Permit <br /> Pump inspection By Q j]� �a \Date( 1,WAA U WAIVER Received <br /> Sol Boring inspection By Date Constructed Well Depth h <br /> COMMENTS <br /> PE SC I Received Check#i Amount Permit/Date Inwice* Well 1D# <br /> Codes Info B ash Remitted Service Request': <br /> d. <br /> l i <br /> EHD 47.176 01332-b/�2'j� WE1l loU!1 PE71 r]IT <br /> -0570'12 r <br /> 8'd VZSU-9960Z Dul SaalluQ GOU21AAnd d00:90 ZO L L End <br />