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0SH'ONAV6l 0l-LIOZ-U A;S—awII paAIa0;� <br />WELUPUMP PERMIT <br />SAI: J OAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENIxe-STOCKTQM CA 95205 - (209)4683424 <br />NUN-ME.=UNDABLE rewnlT tiPILL. tz1.19) 953-7697 FOR MPECTIONS EXPIRES 1 YEAR FROM DATEISSU <br />JOB ADDRESS 155 N Duncan Rd /j CityOp Linden CA 95236 <br />CROSS STREEE O Qp e r O D O i l S R d APN 1 05 11 0 1 $ PARCEL SIZE %- IgLAND USE APPLICATION <br />OWNER NAMEJames A La orio 4-440- Tr— PHC E209-887-3554 <br />OWNER ADDRESS 155 N Duncan Rd CITYISTATFIZItL i n d e n CA 95236 <br />C0KTR CrOR Purviance Drillers, Inc. PHO,209-887-3554 <br />CONTRACTOR ADDRESS P• O .Box 64 CITY/STATE1z1P Linden, CA 95236 <br />SUBOOMTRAeToR PHONE <br />X- C.57 ! 1 C-61 - D-09 <br />CITY/STATE/Z1P <br />NUIRBER 3 7 7 9 2 3 E%PIRATiou <br />GFOGRAPHIDALINFoRNATION' Coordinates X Y Township_ Range Section <br />_NTENWI3U9F Domestic/Private - IrrigationlAgricutiural .:1 Industrial u Water Quality Moritoring I., Sod Sampling/Characterization <br />L: Public Water System <br />Ildiffetenttorn Owne- ys em — o Mor MOHO NUMbal <br />TYPE OFWORK I.1 New Well L Replacement Well U Well A teratlonrModif3cation I.., Otter <br />n Mcnitorin Wells # of wells rl Soil Bo N orbor4gs a of borings <br />9 O rings) r GeoreGhnicrd <br />in Out -Of -Service Well I I Out -Of -Service Well Renewal r Cross -Connection Repair <br />Drilling Method L! Mud Rotary t Air Rotary =Auger t1 Cable Tool j Push Point I.I Other <br />Proposed Well Depth ft Excavation in diameter C Open Bottom 0 Gravel Paclr/Grevel Size in ciameler <br />,; Conductor Casing in diameter I Conductor Casing Depth tt <br />Well Casing Diameter _ in ThidmessfGauge(ASTM Schad i Steel L Plaslic Stainless Steel r_. Other <br />Grout Seal Depth ft G Neat Cement (94 1b bag'S10 gal wafer) a Sand Cement Sark mull gad water <br />r' Bentonite (20% solids) r• Other <br />Grout Placement Method L Pumpad G Free Fall _ Other 7 Retardant I Accelerator (name) <br />PEDESTAL Installed By !Driller ❑ Pump Contractor C Other <br />1.1 Concrete Pedestal LDfinertsions: Width ft Length ItThick in U ChristyBots u Stove Pipe <br />B nP ydSubmersibleu Turbine u Other HP Pump 5 ft Standing Water Level I 114ta R <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORT( WILL BE DONE IN ACCORDANCE WITH SAN <br />.IOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />INIM 24 H NCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 96)1-7697 <br />SIGNED �TITLEC o r p Secretary DATE --�17 <br />I <br />D <br />0 <br />X <br />t <br />GroutInspection By Date 0 SPECIAL Well Permit <br />Pump <br />PumptnspectionBy Date � 0 WAIVER Received <br />Sal Boring Inspection By Date Constructed 'Mall Depth ft <br />COMMENTS <br />PE <br />Codes <br />SC Received <br />info B <br />CheckW <br />Cash <br />Amount Date Permit, Invoices Well 109 <br />Remitted Service Request 1$ <br />quo <br />S � <br />Z' <br />C <br />i <br />EM 43/06 <br />40302 <br />(:�R-/ �d778-zD <br />WELL JPL'NP PERMIT <br />-�'d VLSOL996OZ out saelyaa eoueinand e8 L:O L L 6 SZ deS <br />