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ppf MeN <br />REcENE <br />SEP 1 i <br />JO 11QUPN <br />SAIeogaNM <br />HEAL pEP <br />9SN "N AVLS:II LIN '8 'd;S aulil paA!;3;� <br />Q <br />WELL/PUMP PERMIT <br />SAN Jonoun COUNTY EwinormENrAL HEALTH DEPAR TrdE VT 1868 EAST HAZELTON AVENUE - Smcf(TON CA 952(15 - (209) 466-3420 <br />IV-KEFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />AoDRIM 11264 E Kettleman ):it ct,1h, Lodi 95240 <br />ss STREET T r e t h e w a p APNI 0 6 00 1PARCHV' LAND US E APPUCATTON # <br />!ER NAME Bri.t-talia Ventures (Kho,l U -S'. LLO P.a09-941-4500 <br />IER ADORESs P. 0. B O x 170 _ GIT ,S,,,J i n d e n 95236 <br />TRACTOR Purviance Drillers, Inc. P"09-887-3554 <br />TRACTOR ADoREss P. C .Box 64 CITYISTATE/71P Linden , CA 9 5 2 3 6 <br />:ONTRACTOR PHOr1E <br />ADDRESS <br />L c -y :.e C-61 l: 609 U other NUMBER <br />Cn-dSTATEMP <br />EtviRATIoN <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township _ Range Section <br />L"' EWPED USE C DomesffalPrivate 10 inigation/Agricultural O 1nefustrial U Water Qualily Morrtoting ;! Soil San7pring/Characterization <br />I- Public Water System <br />lfdrferefin°m Owner, Wei. bysim HMO "Ma ane or RwR11,10MIRF <br />TYPE VFWORK -' New Well Replacement Well L Well Alteration/Modification LI Other <br />- Monitoring Walgs) 0 O Wells ;;Sal BOnng(s) golooWas r Geotechnical s°l bore"s <br />Out -Of -Service tn(eU 1; Out -01 -Service Well Renewal f: Cross -Connection Repair _T <br />Drilling Method Mud Rotary L Air Rotary - Auger L : Cable Tool : Push Point u Other <br />Proposed Well Depth tt Excavation in diameter O Open Bottom 7-1 Gravel Pack/Gravel Size In diarnete <br />Li Conductor Casing in diameter / Conductor Casing Depth M <br />Well Casing Oiame ter _ in Thid(ne3VGaugeJASTM Sched ^_ Steel fi Plastic C Stainless Steel r', Other <br />Grout Seal Depth_'I . Neat Cement 04 ib bag'S 10 gaf welet) C Sand Cement sack mtic'7 gal watt <br />n Benlonhe(20%solids) ,-I Other <br />Grout Placement N ethod G Pumped G Free Fall ri Other ❑ Retardant IAcceterator (name) <br />PEDES rAL Installed By 0 Drifter j Pump Contractor - Other <br />U Concrete Pedestal �- Dimensions: \'Urdth ft Length h Thick In ; 1 CnriStY Bots u Stove Plpe <br />PUMP •..: Submersitiled Turbine 12 Other HP Pump Set / 12�ft Standing Water Level _ it <br />HEREBY CERTIFY THAT 1 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 1 AM IIN COMPLIANCE WITH ALL <br />MINI M 24MIRIVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209) 153 769 <br />TtTLEC o r p Secretary DAtE / 7 <br />�DEPARTMENT USE ONLY <br />Application Accepted By W V — Date q' -7 Area 041 Employee ID# G s Se"i v <br />Grout Irspedion By Date O SPECIAL Well Permit <br />Pump Inspection By i Data ❑ WAIVER Received <br />Soil Boring 1spection ey O e� Constructed Well Depth <br />COMMENTS r U Y11A U1 0 Iv .fUf n � AJ l L, I A, _ /I I .. ( L <br />PE <br />Codes <br />SC Received Check#) <br />info B ash <br />Amount <br />Remitted <br />Date <br />Permit/ ItTvace# Well IDN <br />Service RequestAt <br />u3�► <br />�s� <br />3� <br />uvie <br />a- <br />ArN 12 (/�/ 401,32-e;-- <br />J{i 1 "J2 WELL/PUMP PEAMn <br />9'd VLSCL9960Z <br />M <br />M <br />-� 0 <br />o Mtoo <br />ea <br />< <br />rrT <br />C7 <br />( r02314 <br />out sielpa eoueuund e£9: L L L L 20 deS <br />