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Z6SZ 'ON Wb90:l1 M6 til 'AON MI J paAI;3;� <br />WELL/PUMP PERMIT l� <br />SAN JOAQUIN COUNTY ENVRONMENTALHEALTH DEPARIPMNT 1868 EASTHAMToN AvENuE - SrocmN CA 95205 - 4209)468.3420 <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FORINSPECTIOJDIS_ EXPII$ 1 YEF}}pNI�ATE ISSUED <br />Joe ADDMss 9 415 ��e n t s R d -- L ti(p� �'�R— <br />CROSSSTREETMessiClc APN065-150-10 PARGELSIZE '�•�tJWp USE ADPL CAl10710 <br />OWNER NAME Lu_ndblad Brothers/LV&OA-LA PAw NONE 209-887-3432 <br />OWNER ADDRESS P.O. Box 99 C„y,/S-rATFJZiP L i n d e n CA 95236 <br />CONTRACTOR Purviance Drillers, Inc PHONE 209-887-3554 <br />CONTRACTOR ADOREss PO Box 64 0rifSTATEMPL i n d e n, CA 95236 <br />ONIRACTOR ADDRESS <br />CI TY/STATEMP <br />PHONE <br />{ LICENSE R C57 7 "I U D -W U 011ier - <br />DOMESTIC WELL SAMPLING: ❑ Genera( MineralfColiforTn Bacteria (4391) - Dibromochloroorooane (43991 -, Amenie rdaoat <br />INTENDED Use G Domes*J- Private 11 Irrigation/Agricultural G Industrial 0 Water Quality Monitoring 0 Soil Sampling/Characterizatton <br />❑ Public Water System <br />If eiirenarl from Owner. Water System Nam contact Name er Phone Number <br />�F.--t—u u vvealVuerautxvmoamcman U utner <br />0 Monitoring Well(s) # of we11s ❑ soil Boring(s) . ar txmms n Geotechnical _ <br />C Out -OF -Service Well C Out -OT -Service Well Renewal 0 Cross -Connection Repair <br />A or Wnngs <br />Drilling Method 11 Mud Rotary ❑ Air Rolery 0 Anger ❑ Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth_ft Excavation in diameter J Open Bottom 0 Gravel Pack/GrHvel Size in diameter <br />❑ Conductor Casing In diameter I Conductor Caving Depth tt <br />Well Casing Dameter _ in ThlckressfGaugvJASTM Srhed 0 Steel O Plastic O Stainless Steel Collier <br />Grout Seal Depth ft D Neat Cement (94 /b bag5-10 gal waled 0 Sand Cement sack rraiR gal water <br />0 Bentonile(20%solids) D Other <br />!Grout Placement Method 0 Pumped 0 Free Fall : Other D Retardant( Acceleratcr(name) <br />PEDESTAL Installed By 0 ❑nller ❑ Pump CantraAgr ❑ Other <br />0 Concrete Pedestal ODimensions: Width fl Length ft Thick in 9 Christy Box R Stove Plpe <br />POMP D SubmersNeW Turbine 0 Other HP Pump Set O ft Standing Water Level tt <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL HE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQ(ARED LICENSE IS <br />CURRENT AND ACTIVE WITH THE CAUFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />24 DV NCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 954-769T <br />T,Lporporate Secretar&, 11 13 is - <br />0 <br />�O►,C * _100l afidn Accepted By <br />EMn� D TM Grout InspectJon By <br />NF1) Pump Inspection By <br />Soil Boeng Inspecfion By <br />COMMENTS <br />PA/RTMENTSE ONLY <br />De le 11 '- <br />Dale <br />Date <br />Date <br />S <br />n <br />N <br />■■NEEM■■EE!■�/■■ <br />■EN■■■NEE■!■MEN. <br />I' <br />■■■■■■M■!■N■■■■.� <br />1:f�7O <br />■ENE■NEE■■ENEE■ <br />,. <br />NIMEMIMMIN MESONS <br />==EMEM <br />■■!E■■■NNE■M■E! <br />fui <br />.e <br />FFi0< 4)6 a1)1116 <br />vieu iPuk? PERMR <br />E d VL5£L9960Z out slelp4 eoueimnd d00:Z6 LL t,6 AoN <br />1:f�7O <br />n ' u 1G1 <br />i�_� <br />==EMEM <br />Ia�M�01�601 <br />FFi0< 4)6 a1)1116 <br />vieu iPuk? PERMR <br />E d VL5£L9960Z out slelp4 eoueimnd d00:Z6 LL t,6 AoN <br />