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8Ko "N AdSl:ti 8 l 0 Z -1 'Id,�y quail panlaaa� <br />1NELL/PUMP PERMIT ✓' <br />Sar+JoanuutCGUKrfEr'MCNMENTALHEALT1111DEPARWSrrr 1EGaEAsTHezEi_ToNAvEKuE-SToeKMNCA4520S - (2D9)48&342U <br />NON REFUNDABLE PEM, T CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 9 YEAR FRom DATE tSs11F_D <br />155 N <br />Duncan P0.y <br />�,,mpL�nrien CA 9236 <br />D <br />J�ADOR� <br />eROss stReEr C o p p e r 0 <br />p o J. 7. s R �N 1 0 51101,13 <br />PARCELSIZER I LA. UsEAPVucATtarltt <br />a <br />James <br />A Lagogio -i <br />PIiONE?09-4717591 <br />H <br />o,,�w,,,E <br />otwrert AeDREss 1 155 N <br />Duncan Rd <br />cR,./srAT jzr , i n d e n CA 95236 <br />Purviance Drillers, Inc <br />PltaxE 2n9-887-3554 <br />CONTRACTOR <br />PO <br />Bog 64 <br />CrTYrsrATSZPL i n d e n, CA 95236 <br />CavrRacrw Aonm s <br />SUBCONTRACTOR <br />PHIJpE <br />SUECOMRACTCR ADDRESS <br />C lYISTATEILa <br />uce,t3l= `4 C -sr n C-61 <br />❑ D-09 u Other NumsEEk eopm-non DATE_ 7 ' 31 -1 �! <br />DcuEsmc WriiSArApuN3: C General MinerauCoBlorrn Bacteria (4399) -. . Dibromochtoropmpane (4392)1- Arsenic (4393) <br />IWE:NTI ED USE O DommaciPrivale Of Irrigaliioir/Agrtatihrral G Industrial C Water Quality Morvloring O Sel Sempliing7Characleriaagon <br />f3 Public Water System <br />IfGdetentf/om Omer. Water57nemNa Caittaa N—orPhoneNuaa- <br />TYPE OF WORK C? New well C Repleeement WCg, C Well AlreralloruMcd&atien DOther nu <br />0 MordtotingWeil(s) Out wells u SaJ@otin+;(s) saracnngs T' GeoierJmic2t 9or00ngs <br />D Out -Of- ree VVAI C Out-OfService Well Renewal D Cross-Conneaun Repair N JOA <br />to NenrrPurna G Pump Replacement G Pump Repair -_ -- D Raise Welt Castnn PA <br />WELLCoErsTRucmcrN HEALTH <br />Drilling Method D Mud Rotary C Alf Rotary D Auger C Cable Tool D Pusn Point D Other <br />Proposed Welt Depth ft E=avation in diameter Ft Open Botlom 0 Gravel PaWGraval SaE m diameter <br />r] Conductor Casing in diameter / Cortd ¢[or Casng pep h ft <br />Well Casing Diameter _ In Thi6mes3fGtu l;elA,STM Silted 7 Stee] 7 Plastic ❑ Stakiless Steel D Other <br />Grout Seal Oepth R 0 Neat Cement (94 lb Oay5-10 gal water) = Sand Cement sack 51EIR gal waler <br />❑ Bentonite (20% soEds) 0 Other <br />Grout Placement Method L Pumped ❑ Free Fall 7 Other G Retartlanl I A=Ierldcr (carne) <br />PEnESTAL Installed By ❑ Driller 0 Purnp Contractor ❑ Omer <br />ci Can^rate Pedestal ODlmenslons: Weth ft Langth ftThi ck in O ChrisTy Box ❑ Stwa Pipa 1 <br />PITmpR Submersble❑ Turbine 0 Other HIP_ Pump Set it Stan dng Weler Level fl <br />I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK Witt BE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY ORDONANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT FAY REQUUZM LICENSE IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND TRAT 1 AM IN COMPLIANCE WITH ALL <br />WTl ON <br />VJiNIM 24 ANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209) 952-76997 <br />�!/L�'�.'�c ,corporate Secretar>_ATE =a/ <br />A_Ae v l <br />16 2018 <br />� <br />AN COUNTY <br />P TMENT U E 0/ Y n ��/(/�� <br />Application Accepted By Dale ( Area--�� G� Employee IMAIO A <br />Grout Iaspectlan By Date 0 SPECIAL We11 Pelrtlit <br />Pump lnsperllonBY Date= ❑ vNAtvERRiecoffed <br />Soil Baring Inspec ion By Date Constructed Well Depth it <br />COMMENTS _ <br />FTl D 43-0B enifis <br />Z -d tZGU9860Z out SaaIIi.lQ e01-12In.lnd dE0:ti0 9 L � Ladd <br />