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ti[CjE "N 09` 1 Ml '[Z'A�A aulil paAI;3;� <br />' iNELUPUMP PI=RiYliT <br />P✓� i <br />Sato JOACM COUM ENVIRONMBMLHFALTH DEPARVaNT 1868 EAST HPZEl TQN AVMLlE-STOCRTM CA 9UDS - (209) 4&13.1420 <br />N-KEFUNDABLE NE MIT GALL 10y &b3-/tiy/ FOR INS <br />Aan,28915 Funck Rd <br />CkassSitrEETJ,w=/4 APN O - <br />Bright View� 1 9'/� <br />Tree <br />'/ Co <br />Qi1NE.`i-1.� O. X-- 5 C) <br />,/W� Y L <br />CA.VIRACTOR Purvisnce Drillers, Inc <br />Co,urRAcrua Anorrss PO B O x 64 <br />i <br />Sue caIJTRAcro R <br />Stmcov, TRACTOR AD71FIERS <br />Lc'atss -X C-57 ❑ C &T <br />D D -W 0 <br />_ cmrzlP Farmington CA 952 <br />MEL S I l rm USE APFucATION <br />`( �V T�(Dqx,909-482-1734 <br />trTvrsrAtFJZI? 1 J 17`il I a n ri 31 1 <br />CA <br />Pnonx 209-897-3554 <br />crnrsTAwzmLinden, CA 95236 <br />PHcr4E <br />CMISTATEIZZIP <br />Numam y1 E a`IRk''RfjN <br />Doiaanm WEi-L Sna>Futuo_ ❑ General MinemliCodrom Bacteria (4391) ,T. Dibromochlompropane (4392) = Arsenic (4393) <br />NTEN DED ruse p Comestinrpritate Irrigation/Agdcaittual C Industrial C Was Quality Rtcrilodng 0 Soil SamplinglChaacienzabon <br />L Public Wale System <br />r Qdau¢(nm Owa� WOer Syvenffe Carlad Nares ar Prune Number <br />ME OF rryORK G New YVeli C RE19arement Wel) C Well AlteralloNMcdffiraticn O 011ier <br />❑ N{aniioting N7elI(Sl # a1wP3s G San 8orin9(s) �moor�s r, Geaeatn(cet a � <br />❑ 0ut-0"erviee Well ,C Oul-0rSenrice 1AU Rene%v l O Crass-Cannedica Repair -?T <br />Dntling IAeUrod G MU* RO:aly C AY Rotary : At[Jer O CaCIOT001 ''3 Push Point ❑ ODrer I'9/' <br />Proposed Well Depth ft Excavator, In diameter G Open Eotlam G Gravel PackiGrarel 5ae� in dame <br />❑CondtMorCaGxg indiattele r Condo;o.-Ca5ingDepth ft JOAQIJ <br />Well Casing Diameter____ in ThiumesslGaugefASTLA Sched Steel ❑ PiaStir ❑Stn nim. Sical 0 Ol <br />Grout Seal Depth R D Neat CernenL (94 16 bags -10 gal watery 7 SEnd Cement �l <br />0 Bentonite (20%sallls) 3 Other <br />Gceut Placement Method C Pumped O Fre© Fal 7 Other C Retardant fArcelcmtor (name) <br />PEM=AL Installed By C Driller D Ptanp Contractor 3 Other <br />G Concrete Pedestal 00Irrans1ons: W;dlh tt Length It Thitle irr . Christy Bos ? Steve Plpe <br />u IP D Suhma s:bI Turbine C' wer HPO.,LO Pump Set 1 it Standing Wales Level t1 <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />1OAQUIN COUNTY ORDINANCES, STATE LAWS, AND RIAES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICB,GE IS <br />CURRENT AND ACTIVE UUlT7-I THE CALIFORNIA CONTRACTORS STATE 1JCENSE BOARD AND THAT I AM IN COMPLIANCE VATH ALL <br />l'1H IIlrlll<ITIM <br />APpl)calidn Accepted By <br />Grout Inspection By <br />Punto lnspec8on BY <br />Soil Boring Inspection By <br />COh'.,'u1ENTS <br />NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />t6l T.,forP(Drate Secretar&, <br />T <br />D <br />c <br />c <br />w)VT <br />V,�® <br />2®18 <br />m <br />Z <br />M <br />o a 0 <br />M <br />.err <br />C=) <br />EP RTMENT U E N y �SIECIALWIII <br />/�DaleAteaEmployee IDlE 'fDate 17 ecPOPrtiit <br />' Date Q > > 0 WAIVER Received <br />Oate Cortstructed Well Depth ft <br />PE Sc Received checw Amount�� Permlt/ Invoices WallIDm <br />.costes Info Cash Remitted Service Raq uestF <br />I I <br />Z d VZ9U9960Z OUB 801-1e1A_lnd e6Z:60 9L 2 AeW <br />