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W <br />a <br />Uj <br />W <br />HOE"N Wil 9l 8[0Z 0Z'gW I I paAIaaa� <br />WELUPUMP PERMIT ✓ <br />` SAN JOAouiN CouNTY EwHONMENTALHEALTH DEPARTMENT lOrlS F-ASTNnzouap AvENue-STacKToR CA9S205 - (213S),1169-3420 <br />TION -REFUNDABLE PERMIT CALL 09 953-7697 FOR INSPECTIONS EXPIRES 'I YEAR FROM DATE ISSUED <br />7474 N Cox Rd <br />c,,,,zjinden CA 95236 <br />JooAot>aeEBS <br />D <br />CRoss STREET C O m S t O C SC R d AP <br />PArtcEiSaE (moi ANn UsE -0"f-! oN:z <br />c+3aL-CC0:9— <br />OWNER KQW- Lawrence Sambado <br />J� �DPo 2568 <br />Ov.Aoo�.0. Rox 461 <br />cny/STATIzj-inden CA 115236 <br />Purviance Drillers, <br />IncT PRONE 209-887-3554 <br />CONTRACTOR <br />PC Boz 64 <br />CMISTgTMP L i n d e n, C A 95236 <br />CGNTRACToRADOREW <br />SUBCONTRACTOR <br />PHONE <br />Sufic oNTRAc'foa ADDREss <br />CTTY1SgTAlEQ P <br />3-3)-19 <br />LCENSE C57 0 C-61 El 0-09 U O1hef <br />Ntni®FR 'l7 1222 ewRAi1DN GATE <br />q^u2smeuvE . eAuar u�- n rPnarnl NlineraFfC:olifotm Bacteria (4391) F. obm <br />roochloropropane (4392)=ATSenlC (43v -e) <br />NTEMED USE 0 Domestic/Private Is Intgation/Agncutlural C industrial C. Waler Quality Monitoring 0 Soil Sampling/Charactertzallon <br />O Public Water System <br />ITditrerem rmm Owner. wala-system Neme Caned Name OrPhonefftmte <br />TYPE OF WORK 0 New Welt C Replacernent Wetl C Wed AtieraUOOAMO=CnOn U carer <br />❑ Modlilaing Well(B) 0 Of wells C Sc@ ElO nS(s) A °r ^es 0 GeotecMica! a orm a gs <br />D put-ofSerfm Well C QulOfSenAm Well Renewal C Cess Connect on Repair ` <br />* New Pump r-.. Pump Reptarcmenl It Pump Repair n Raise Well Casing <br />Drllling Method ❑ Mud Ro'.ary C Air R0127y ❑ Auger 0 Cable Tool 0 Push Point ❑ Diher <br />Proposed Well Depth ft Excavallon in dame(er --7 Open Bottom ❑ Gravel PaddGravel Size in diameter <br />f] Conductor Casing in diameter f Conductor Casing Depth R <br />We0 Casing Diameter _ in ThicimesslGauge1ASTM Schad 0 Steel 0 Plastic 0 Stainless Steel 0 Other <br />Grout Seal Deplh ft O Neat Cement (94 it, bagr540 981 water) ❑ Sand Cement sack mbrf7 gal v aler <br />0 Berdonite (20% solids) 00 <br />Grout Placement Method C Pumped 0 Free Fall 0 Other 0 Retardant fACcderatOr (na=) <br />PEDESTAL Installed By O Oriller ❑ Pump Contractor 0 Other <br />❑ConcrewPedestalODlniensions-VMth ft Length ftThick in .I Christy Box ;7 Stove Pipe <br />PUMv 0 Submersibte0 Turbine 0 Other HP Pump Set 8 Standing VJeler Level ft <br />I HEREBY CERTIFY THAT I 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 L10ETlSE IS <br />CURRENT AND ACTIVE VOTH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WO LAWSF5�:ENSATION <br />24 ANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED �orporate <br />7SecretarffTE,_�,?-,::P,->-/r <br />Fz- � <br />1 <br />xL <br />FfOf <br />W <br />W co <br />Application Accepted By <br />zGrotA inspection By <br />0 W Pomp Inspeaon By <br />> a' Sail Boring Inspectan By <br />W COMMENTS <br />P T 119 E N T U E O Y -����-=- <br />Date AreaAL Employee IOltt <br />Date C PM ViFe11 Permit <br />Date 16 U WAIVER Received <br />Date Constructed Well Depth It <br />0. �° . ... <br />70 119 <br />...�.� I•L.�r1,,lJ <br />9'd VZSU2960Z <br />Fe Z2 Fo <br />°qQU, �OjB <br />�F,o RFT �N�Y <br />MF'vT <br />OU1 S.lejj!.lQ aOueiAind ept,: L L 9 L OZ qed <br />