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fl10 cl 'add au�l paAiaaa� <br />WELL/PUMP PERMIT ✓ <br />SAN JoAcus COUNTY EWIRONMENTAL HEALTH D EPARTMENT 1866 EAST HAztTON AVENUE. SmctCTON CA 95205 - (20B) 4863420 <br />NON-REFutvASLE PERMIT CALL 20 9S3 7697 FOR iNSPECnONS EXPIRES i YEAR FROM DATE ISSUED <br />JonAocRess 16150 E Sar. p enL R' a,rz,,J.odi CA 95240 <br />CROSS STREET T u 11 `j R d APN 053 —��Q l PARcELS¢L /S •M.-APPUCAT10N H <br />OWNER NAME T t i C �%!_ 1, i�DB W k� Tr' Pwxr _2_9 <br />OWNER ADnRsss " 91 8 9 N A s h l ey L a n eCrn JsTATElZ P S t o c k ton CA 95212 <br />CONTRACTOR Purviance Drillers, Inc PHomE 209-887-3554 <br />CONTRACTOR ADDRESS ?0 Bog 64 CmJSTATEOPL i n d e n, CA 95236 <br />SUBCOVTRACTnR PHcME <br />SUBCUN`rRACTOR AuDRE45 C rYISTATEZ <br />LicalSE X C-57 0 C-61 7 D-09 U 0111er NUMBER ExPMA*noll DATE <br />❑ctaesnc tNEt.LSAwLjxo: C General Min erallCohlorm Bacte a (4391) i Dibrarnochloropropane (4392) --Arsenic (4393) <br />tNTENOE:'O USE ❑ OumestlrJPrivate '�IRigaUaNAgrie�ltural C Industrial O Water Ou"t Monilnring 0 Sal Sampting)Charzcledzalion <br />O P:,blicwewsy�l�m <br />lfmfi¢Lttt lmm O�rner. VWerSystwn Name CoKad tLxme arPMrte NumiW <br />TYPF.dF WORK 0 New LrVeJI [ Replecernent Well C Wdi NterdtirnlMaddff©tion 0 Other <br />O tvlorftTingV'1PJI(s) # OFWe1's C Sort Boting(s) &ormrr"g' G Ge0eOnical aorao+y�� <br />D Out-0FSeniceWell C Ohl-OfSevice Well Renexral 0 Crass -Connection tDpair <br />Cl Nwi Puma I WPumpR ent ❑ Pump Rcpnir ❑ Raise Well Casin wa <br />W�Lt. CcN:s.MUGT 0K r <br />DrillingMethodD Mud Rosary C Air Rotary D Auger 0 CatleTool 0 Push Point ❑ Othas it <br />Proposed Well Dcpih ft Excavation in dlameler D Open Bottom D Gravel Pack/Grevd Size diameter <br />D ConduCorCasing indcameter / ConductorCasngDeplh a E.vA�QUIIV <br />Well Casing Drarneter_ at ThidvtesslGaugetASTIO Sched D Steel O Plaatc O StanIPSSSteel U OIb <br />HIP <br />Grout Seal Depth R DNeat Cement (941bbop/_'10gat uo" .3 Sand Cernenl saclr <br />O Bentonite (20:8 solids) 0 Other <br />Grout PldcementMathod G PLTnped Q Free Fall D Other RelardantJAcca;erator(rame)_ <br />L_ T_ Installed By 0 Driller D Pump Contractor 0 Other <br />D Concrete Pede5ml001mensicrrs: Width ft LengEa ttTNck in 0 Christy box D Stove Pipe <br />u' P 0 Submeritl Urh61e D Other HP J yd pump Set h Standing Waley Level fl <br />I HEREBY CERTIFY THAT t 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 CE5TPFY 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 />WIDR,Wtri If ENSATi0N1AW . <br />MIN! 24 NCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL j209) 95 7697 <br />SZaNe� TtTd� o r p o r a t e S e c r e t a r&ATE <br />EP TWENT U E NLY <br />Applkalion Accepted By Dade <br />Grout Inspeelon By Dale <br />Pump Inspeatlon By <br />Dale <br />soil Ba ng Inspection By Dale <br />COMMENTS <br />2018 <br />M <br />-0 <br />z <br />� <br />c <br />M <br />z� <br />S <br />cin <br />Area Employee ID;* l/ <br />0 SPECIAL Ws{i Permit CC%%�� <br />U WAIvERReceived <br />Constructed Weg Depth It <br />lm�[ww_ � <br />• <br />WINIA <br />EH�-5106 `AIM <br />�77X/?7 <br />� d �ZS�Z9960Z 01JI e0Ue1A.md d00 b0 9 L 9l AV <br />