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ZHVIN NMI UO0 -6 'ady anvil paAI;3;� <br />I WELUPUMP PERMIT <br />SAN JOAQUIN COUNTY ENmoNMENTAL HEALTH DEPARTMENT 1 d6a E'ASTHAZELTON AVENUE - SToCRT'oN CA SWOS - (21!9) 4683420 <br />TI VN-11EFUNVAULL rLKMFT GALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR Fgom DATE ISSUED <br />JoeADDRess 6464 Live Oak RD ciwaoLodi 95240 <br />CRossSTREETN Furry RD AP 3—Ojj 6 PARCELStg�LANDUSEApPt-mnoNS <br />I0—E-NAME Pafjf3jTr'reek -Rarmi nT,.._.I,Lf^ PHONE 209-479-8763 <br />OWNERADonEss6464 Live Oak RD c,,rsTATEo,Lodi 95240 <br />CONTRACTOR Purviance Drillers,Inc PHON.;�09-A87-3554 <br />CowmAcTOR ADDRESS P. O. 13 o x 64 QTYISTATEmp L i n cl e n, C A 95236 <br />SUBCONTRACTOR PHONE <br />ADDRESS <br />L C-61 - D-09 J <br />C)TYMATEMP, <br />NUMMER 377923 <br />EXMAT10N DATE 7/31 / 1 <br />GEODRAPHICALIWORMATION: Coordinates X Y Township Range Section <br />INTENDED USE 490omeslic/Privale D Irrigation/Agriwhural D Industdal 7 Water Qualify k4oniloring 0 Sol SamplingrChalaclerizetion <br />U Public Water System <br />lktff0rant from ownen VVtr tiWt.m o o rm cc one r <br />7yPE OF WORK u New Wdl L Replacement Well U Well AlleratioNModifi®tiont I Other <br />n Monitorng Well(s) *or wells n Soil Borings) O cr.6res r Geotechr ical 1) or bolts <br />r. Out -Of -Service Well n Out -01 -Service Well Renewal n Cross-ConneGion Repair <br />D New Pump til Pump Replacement L Pum Re air D Raise Wdi Casing <br />WELL CONSTRUCTION <br />Drilling Method U Mud Rotary AlrRotary -i Auger L� CatleTod i Push Point a Other <br />Proposed Wall Depth_ft Excavation in diameter L Open Bottom ❑ Gravel PacUGravel Size in diameter <br />L' Conductor Casing in diameter / Conductor Casing Depth H <br />Well Casing Diameter _ in TTickness(Gauge/ASTM Schell C Sleet ❑ Plastic C Stainless Sleet ❑ Other <br />Grout Seal Depth R G Neat Cement (94 Ib baa�S10 gal water] E) Sand Cement sack mokP gad water <br />r' Bentcrtlte(20%solids) n Other <br />Grout Placement blethod 0 Pumped O Free Fall L Other D Retardant/Accelerator(name) <br />PEDESTAL Installed By C Driller C Pump Contractor O OU1er <br />Concrete Pedestal --Dimensions: Width ft Length tt Thick in u Christy Box U Stowe Plpe <br />PUMP M Submersibleu Turbine U Other 1-0' PumpStU Standing Water Level 9rY N l <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 />WORKE PENSATION LAWS. <br />MINIM 24 H &DNcE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209) 953-7697 <br />s,atdEDu 7TTtE Corporate SecretafiV <br />ENVI <br />APR <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />'AfTINENT U E OJOUY <br />Date <br />_ Elate��� <br />Date ! - - <br />--- Date <br />v, <br />g <br />w <br />-------------- <br />■■■■■■■■■■110=0 a <br />a <br />■■■■■■■■■■lliCi■■■ 0. / <br />■■■■■■■■■■fit■■■C. . <br />PE Sc Received CheckV Amount �� <br />Codes Into B Cash Rernitted , <br />PertniU Irrvoiee# well [Do <br />Service uestti <br />EFL a..OG <br />V30M2 <br />W 3L IPUTAP PERMLT <br />Z'd tL9U2260Z oul sjelluQ eoueimnd e9t,:80 9 L 60 AV <br />