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a <br />PAYMENT <br />RECEIVED <br />NS 'IN M90: k LIN 'til 'AIN IWI J paAl;3;� <br />WELL/PUMP PERMIT <br />SAN JOAOUDJ COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HA2ELTON AVENUE-STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL (2091953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSI Wn <br />JOB ADDRESS - v v :V I't d. C K V 1 .Lie Ko CITYZP clement s <br />� <br />S�Z-r <br />cRoss STREET C o 11 i e r APN 02115024 (fi <br />PARCEL S¢E c)1 • I LARIp USE APPLICATION # <br />OWNER NAME _B i g l i e r i Farms, FLP PHONE I <br />OWNER ADDRESS P.0 Box 604 CITYISTATEmp Clements , CA 95227 <br />CONTRACTOR Purviancd Drillers, Inc PRONE 209-887-3554 <br />CONTRACTOR ADDRESS P O B o x 64 C rY1STAT`.J7F L i n d e n, C a 9 5 2 3 6 <br />SUBCONTRACTOR <br />PHONE <br />SUBOONTRACTOR ADDRESS CITYISTATVZIP <br />LICENSE EXC-57 D "I D D -O9 U Ogter NUMBER 377923 1E)(PIRATION DATE 7 / 31 / 19 <br />DOMESTIC WELL SAMPLING: D General Mineral/Coliform Bacteria (4391) C Dibronlochloropropane (4392) 7 Arsenic (4393) <br />INTENDED USE 0 Domestic/Private Irrigation /Agricultural O Industrial 0 Waler Quality Monitoring USoil Sampling/Charadenzation <br />0 Public VYWer System <br />IrdlTermn tram Owner. Weter System Name Coreact Name or Poona Nlrnbef <br />TYae 0= WORK D New Well C Replacement Well 0 Weil ACA aliorJModiriication 0 Other <br />O Monitoring V iell(s) # Of yells 0 Soa Boring(s) A of bongs 0 Geotechnical a of wrings <br />0 Out -Of -Service Well O Out -01 -Service Well RenewW J Cross-Conrtedion Repair <br />P New Pump Pump Replacement VPump Repair ❑ Raise Well Casin <br />WELL CDNMUCTION <br />Drifting Method D Mud Rotary G Air Rotary 0 Auger 0 Ceble Tool Push Point 0 Other <br />Proposed Well Depth fl E=avation in diameter 0 Open Bottom 0 Gravel PacklGrauel Size in diameter <br />0 Conductor Casing in diameter / Conductor Casing Depth tt <br />Well Casing Diameter_ in Thickness/Gauge/ASTM Silted :,steel 0 Plaslic 0 Stainless Steel U Olha_ <br />Grout Seal Depth tt 0 Neat Cement (941b bapr5.10 gallMafe)) 7 Sand Cement sack rr. x,7 gal vrater <br />0 Bentonite (20% solids) 0 Other <br />GroutPlacementMethod G Pumped 0 Free Fall 0 Other 0 Retardant lAccelerator (name) <br />PEDESTAL Installed By 0 Driller 7 Pump Contractor 0 Other <br />n Concrete Pedestal00lmensions• Width fl Length ttThick In OC lTnstyBox0 Stove pipe <br />PUMP 0 Submersibles/Turbine -3 Other HP Pump Set N Standng Water Levei fl <br />I 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. 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 />WO COMPEKSATIO <br />MIN UM VA NCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209) 953-7897 <br />ShcNEt�,c`. TITLE C o r p o r Sectary DATE <br />I <br />I <br />i I <br />I <br />I <br />Ngv 1gj <br />°1j ZO1 EP RTMENT USE NLY <br />SAN JOAQUINCO'UHTY Application Accepted By Dale I <br />ENYIRONMEp(TAL Grout Inspection By Dale <br />HEALTH DEPARTUIENT <br />Pump Inspection By Date <br />Sod Boring Inspection By Date <br />COMMENTS_ <br />u <br />M <br />M <br />/v/,G� / m <br />AreaI.-'��4-�-L — Employee 100 Of�/ T� T <br />❑ SPECIAL Well Permit m <br />LI WAIVER Received m ? <br />Constructed Well Depth tt S <br />EO4345 a0via <br />Z•d <br />tL5£L9860Z <br />Well ID# <br />t # Invoice # <br />I3S7� Wal. /PUMP PERMIT <br />M <br />C:) n <br />�. M <br />O <br />iat <br />L -J <br />out sialiu4 eouei/und 1365 L L LL t L AON <br />