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i <br />VVELLIPUMP PERMIT D ' <br />SAN JDAQIM COU14ri fiNFIMI MENIALHEALW D1=PARTI�,eNT 1866 EASTHAZELmNAv81DB-STccKTDN CA 45209 - (ZD9) 468-U2o <br />NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FRoM DATE IssuED <br />1on,Aoortms 5400 E Harney Ln nn {� cmffztpLodi 95240 <br />CRo:sS;.—Er 'At e I i s L fL APN F✓ V �� PagcilS�lz z LnxD 115EAPPucnittsv► i uo� <br />ia%K,g,N,,,T- Color Spot 'Jur v I Pltattc?09-356-7383 <br />nr [f <br />ova,EReoRE,s- 27368 Via Industria Sue <br />it ? 2 7 rDO� I� <br />100PIMAMR Purviance Drillers, Inc <br />CeuTPAcTUR AmF,ss PO Boz 64 <br />SLMCo nTR=0A <br />)R AGDRE3S <br />C 57 a GC1 D 0-C9 u <br />aTE¢n emecu <br />FNt1NE 209-887--3554 <br />cmjSTATF,m,Linden, CA 95236 <br />PHoM <br />LiTYJSTAmm P <br />NWARER ?2,7777 9a <br />EIPIRAZION <br />DDraesttc WVa-L SAMPL;.4SI_ = GSraral Min EraVColiform Bacteria (4391) I)it)mmoChloropr0yane (4392) = Arsenic (4393) <br />InrraroEDI1sE G Do:nesLi'lFdvale Infg.0 WAgdcullural C Industrial C Water Quardp Mortlaring 0 Sal SemP!z g,Charrctenzacan <br />C PuWoi Wets System <br />IId1Qe2Ri tmm Qwnrr- WlterSgstem Nmnr Cracert Nt Cr Pt-Nonrier <br />TWE OF W pR1t <br />G Nt.T, Wet' C ReptaoPmcn[ Wel [Wel Alteral:on'Mod+frratian O Other <br />u moWntiag We9(s) #iYwe!s G Soleoftg(5) °01wa,1' r, GeAlei�mlpl aormnngs <br />J Oui-0E-Service Wen C OuKN-Setvim� Well Renewal 7 Crass-Cannec@on Repair <br />13—"W' Pismo t Pump Rea PumpRepair_ C Raise Welt C,sfnr <br />Drtlltng ethod ❑ Nlud Rola:Y C Alr Rotary 0 Augr DeCable Tool D Push Point D OOTer <br />Pn�posemd 1Vet1 Depth R Euavation in d-tamete <br />Open Bodom L Gravel PatiUGravel S— i,r damgpr <br />❑ Conduc�orCasing hdrameler r CornductorCayjngDepLh fl <br />Wed Casing Diametef in ThicknessiGaualYASTM Sched C Sheet D Plastic D Stemless Steel D cmw <br />Grout Seal Depth R ❑Neal Cement (34 lb Lag/S10 gal urate j 7 Sand Cement sack Mxgal scaler <br />D Bentonite (2D% scOds) C Other <br />Grout Placement Method C Pumped 0 Free Fall 0 011ier C Retardant IAacelembr, (nacos) <br />PEDFsTAL Lns IIM By ❑ Driller 0 J'tmnp Conuarlcr0 Other <br />0 Concrete PedestalODanenslorts-Wrdth h Length ft Thick in ]ChristyBor :� SrovePipe <br />Rina *SubmemiblaoTurbine DOImr HP PwnpSe fl StandngW,,j,LetTl ft <br />1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL aE DONE IN ACCORDANCE VMH SAN <br />JOAQUIN COUNTY ORIYNANCES, STATE LAWS, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CUNT AND ACTIVE 1NLTH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AMID THAT ILLN IN C01 PLIANC2 1tJITH ALL <br />WORKERS CONTPFNSATIDN LAVA. <br />IHQr-AUVjANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7687 <br />SIGNED--L) <br />7A <br />Ji'''!/C s�`t�. T('orDOrate Secretary <br />111� <br />Applicabdn Atxei2ed By <br />GmuI Mspectlon By <br />Pump Inspedon 9y <br />Sed Boring Inspection By <br />COMMENTS <br />T M E N T U �E�0OV_ 1 <br />DWe r— <br />Cale ri <br />cam <br />Area=—q EMMo`�ee IRY [� <br />CI SPECIAL Well PerMit <br />UUALVER Received <br />Constructed Well Depth R <br />44y2 "v4i <br />SOI 2018 <br />yzR l✓iN <br />No pMF,y�U,yl}, <br />E d bZ9U2H0Z <br />OUB S.1811uQ eoueiA.Ind d85Z0 8L 8L AeN <br />