Laserfiche WebLink
MCC- 10N Wd�l;� 8102 �l '1dy quill paAiaaa� <br />V i <br />WELUPUMP PERMIT <br />SAN.IOAOUVI COUNTY ENVfRO`IMENTAL HEALTH DEPARTMENT 1868 EASTNnzELTcm AvmuE-STDCKTan CA 95205 - (2091 46&)420 <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR IMISPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />ioa AnDrEss 10660 E Kettleman Ln — crrvrz odi CA 95240 <br />ICpp= STREET N N W Y 88 APN O— 0 LP—cELSHE ELAND USE APPLICATION$ <br />Owrtr_R NwiE Wayne Utley UTG-q/FL,dY�' �,� � J 17 PHo�E 20 9— 3 2 9— 6 99 7 <br />OwmF.R AoonES510 6 6 0 E K c t t l e m a n Ln clTwsTATcwPL o d i CA 95240 <br />CONTRACTOR Purviance grillers, Inc PHO�7NE 209-887-3554 <br />CONTRACTOR ADDRESS PD B o x 64 CTTYISTATFILPL i n d e n, CA 95236 <br />SUBCONTRACTOR PHONE <br />SUBCDNTFtAOTOR ADDRESS CRYIS7ATEMP <br />t_SCENSE C-57 ❑ G6T U 6-09 U Othor NumeEaR EXPWAITON OATS <br />00W3T1C WaL SAMPUNr9_ C General MinelallColiform Bacteria (4391) F. Dibrornochlofopropane (4382) - Arsenic (6393) <br />IrrTFNDED VsE • Dorne_s9aPrivale ❑ tnt'gationlAgciwltural G Industrial C WaterOuafity Monitoring O Soil Sartrprrrlg/Charstenzallon gy <br />13Pubtic Water Sy9tern t <br />If,fwerent rmm Owner vlerer Sptemlreme Caned Harte ar Phone Nu b6 C, <br />rr <br />TYPEpFW6RR ❑ NewWoll G Replecernanl Well C VMI AlleratioNModifitaRon 0 Other ' � <br />❑ Mtretonag Weil(s) it of wou G Sal Boring(s) 9°t auangs 0 Geotechnical a or donnas <br />❑ Out-OfService Well G OutOfSerucee Well Renevmt -1 Cross-Conneclion Repair �'' 4p p <br />Cl New Pump W Pip Replacement a Pump Repair 3 Raise Welt Casing <br />Drllling Method ❑ Mud Rotary ❑ Air Rotary 0 Auger n Cable Toot 0 Push Point ❑ Other "KI <br />Proposed Well Depth ft Excavaton in diasneior :1 Open Bottom ❑ Gravel PaduGravel Size �(dernD <br />C Conductor Casing in diameter I Conductor Casing Depth ft f7 Ell <br />Well Casing Ciameter. _ en TNdmesatGaugNASITo1 SChed =Sleet 0 Plastic O Stainless Steel 0 Olhor <br />Grout Seal Depth ft O Neat Cement 194 16 bagc5 f0 gel watarJ ❑ Sand Cement sack rnld7 gal vater, <br />C Berflonite(20%solids) D Other <br />Groat Placmnernt0.9ethod L Pumped 0 Free Fall D Other D Retardant I Accebarator (name) <br />PEDESTAL Installed By U Driller a Pump Contractor ❑ Other <br />C Concrete Pedestal ODimensions. Width ft Length It ThIcY in O Christy Box II Stove Pipe <br />41SutimersibloO TurUine 0 Other HP Pump Set fl Standing Water Level <br />I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION ANDItHAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />IOAOUM COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY RMU1RED LICENSE IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE V fM ALL <br />MAJM 24 HO NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209) 953-7697 <br />�CE <br />�' Trh_�orporate Secretar&,, /57 <br />Application Accepted By <br />Grout inspection By <br />Ptanp Inspection By <br />Soil Elorfrip inspection BY <br />COMMENTS <br />8 ?018 <br />rCOUN�. <br />EP RTMENT U E qNI,,Y <br />Dale Area_' Employee <br />Date 7 Well Permit <br />pate h J WAIVERAfvER Reeelved <br />Date Constructed Well Depth it <br />EHV4> W WrIE 5)W. 'i / / �,/ r G 1 <br />(�'d VZ9U9860Z Out S.lajji.lQ eOueiAind d(�0 t o 9 E L idy <br />'ro 011 <br />rA IM 13 MAN RMPORMUM0,04. <br />EHV4> W WrIE 5)W. 'i / / �,/ r G 1 <br />(�'d VZ9U9860Z Out S.lajji.lQ eOueiAind d(�0 t o 9 E L idy <br />