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Uj <br />'e� <br />Ui <br />0 <br />Uf <br />w <br />l <br />HOPIN ACCO:01 � 10 �Z -(1aj atuil paAiaaa� <br />VVELUPUMP PERMIT <br />SAN JOAOUIN COUNTY EwRDNMENTAL HEALTH DEPARTMENT i ae 8 EASTNA7tll-TDN Aum era - SmcKTON C A 9SZDS - (209) 458-3420 <br />NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS tJ[MIKC, I I t_ -AK r-KUM UH I C -, UC <br />.IOa AoDRESS 250 Roth Rd cayap Lathrop CA 95330 <br />CROs STREET Har 1 a n Rd APN /Qb - b ' 4 PARCELsIZE -S�FANT1 IUE ArPs=ATtnN <br />01-414 ER NAmD i .� i o, r HOtiw�?wrop <br />ipa <br />onNERAoDr:Ese25U E Roth RD ?j Q 5sCA 95330 <br />CON-MACTOR Purviance Drillers, Inc PHONE 209-887-3554 <br />CoNTRAcmit ADDRESS PO Box 64 C"yISTATEM,Linden, CA 95236 <br />SUBCON RACMR PROM <br />4uecoNTRACIDA ADDRESS CITISTATFJZIP <br />L]CEN6E CS7 ❑ Cr6T G 11{19 0 Other Nuwar.R / L ✓ E�a4RATION DATE 1 - I <br />n...._o,„-vtr_ gAMpI inr.- r, raneral MinerallCoSifotm Bacteria (4391) C. Dibtomochloropropane (4392) 7— Arsenio (4393) <br />INTEND® UaE 0 Domestic/Private D hrigalionlAgrialtural dusfrial C Water Quality Uonitoring 0 Sal Sampling/Characlertmdon <br />❑ PubBC Water System <br />Irdinemm"M Omer. Water System Name Coaled Name orPhomftnit r <br />TYPE Or WORK 0 NBv/ Well C Replacement Well C Well AlteraWnrMoOtnraeon u Umer <br />0 Monitoring 1VW%s) # of wails L Sal Boting(s) s a borUW L Geolechniad aal bOMW <br />0 Out-OfSerice Well C. Out -Of -Service Well Renevral O Cross-CionneCdDn Repatr T' <br />Drilling Method D Mud Rotary C Afr Rotary ❑ Auger ❑ Cable Tool 0 Push Point O Other <br />Proposed Well Depth ft Excavation in diameter —1 Open Bottom C Gravel PaWGravel Size in WarTleler <br />D CondutdorCasing in diameter I Conductor Casing Clepth ft <br />Well casing Diameter_ In Thirlotess/GRuge1ASTM Sched 7 ! D Plastic 3 <br />SteeStainless Steel ❑ Other <br />Grout Seal Depth ft f1 Neat Cement (94 lb ba85-10 ga(water) C Sand cement sear mw/7 gal rester <br />D Bentonile(20%sotids) ❑ Other <br />Grout Placement Method C Pumped ❑ FreeFa11 0 Other 0 Retardant IAccelP.rstor(name) <br />PEDESTAL Installed By 0 Driller 3 Pump Contractor ❑ Other <br />I3 Concrete Pedestal CD1nwnsions: Width h Length ft Thick in O Christy Box 0 Stove Plpe <br />PUMp 11 SubmersibleO Turbine 0 Dlher. HP Pump Se ft Standing Water Level XT ft I <br />1 HEREBY CERI7FY 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. I ALSO CERnFY TFWT MY REWRED L)CENSE IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORHERS COMPENSATION LAWS, <br />MINI IN 24 VANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209) 95p3-7697 <br />S1nraEn T4orporate Secretar&AT,� <br />co 1-13L0PA TMENT U E y <br />O 2U <br />C V Application Accepted By Dale Area F1nPbyee I <br />Q I-" W Grout Inspection By Cate 0 SPECIAL WBII POMI t <br />Z CJ WAIVER Received <br />W Pump Inspection By Date <br />Gale Constructed Well Depth <br />M G �Sail Boring inspection By <br />„A =&AMENTS - — <br />(n <br />a <br />m <br />xi <br />I I <br />EHoaua evtna 6W! 5-772#1/ <br />9'd VZSCZ9260Z <br />Y'SLLIPUMP PERNIT <br />out Saa11i1Q aoueiA-md ett L L 9L OZ qed <br />