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HN "N Wd9Z:6 LIN '6I 'aaS awil paAiaO�d <br />✓YY <br />SAN JOAQUIN COUTY EI'rvONMENTAL HEALTH DEPARTMENT <br />MPPERMIT <br />EA T <br />NRMHAMTON AVENUE -STOCKTON CA 95205 - [2091 daa-u?n �1 <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS _EXPIRES 1 YEAR FROM DATE ISSUED <br />iJOBADDREss 14993 E Hwy 26 C1v1zt�Iinden CA 95236 <br />jCROSS STReW a c k T o n e Rd APN d C(` 613PARCEL SZE -(e-Q_LAND USE APPLIATION 9 <br />ow,E.N,,,,E A1vin.UCortopass i � � �� PHCNF209-931-2563 <br />OWNER ADORE33 14993 E Hwy 26 CITymirAtivap Linden CA 95236 <br />CONTRACTOR Purviance Drillers, Inc. PH,,209-887-3554 <br />CONTRACTOR ADDRESS P. O .Box 64 CI iYJSTA-WZIP Linden, CA 95236 <br />SUBCONTRACTOR PHOLE <br />SUBCOWMACCTOR ADDRESS CITYIISTATSIZIP <br />LICENSE A.i C-57 J C-51 i D-09 J Other NUMBER 3 7 r 9 2 EXPRATON DATE 7 I /19 <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township Rance Section <br />INTENDED Usr 9 DomestictPrivale -1 Inigalion/Agdc:unural G Industrial :.I Water Quality.Lbnitoring U Sol Sampling/Charadwizabon <br />IJ Public Water System <br />IfdhTerent fmm Owner. Water SyrA em.une cwlacl Niame cr FRIO& NaMber <br />I YVE VF WORK L Ivey VVel . Replacement Well U Well Alteration/Modification L: Other <br />Monitoring 'Nell(s) al` of wells n Soil Bcring(s) A of borings r Geotechnical u a wnngs <br />Out -Of -Service Well I I Out -Of -Service Well Renewal i: CrossConnectlon Repafr —T <br />Haae <br />Drilling Method i Mud Rotary _ Air Rotary J Auger a Cable Tool Push Point Ll Other <br />Proposed Well Depth ft Excavation it diameter C Open Bottom n Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter i Conductor Casing Depth R <br />Well Casing Diameter _ in Thidmess/GaugeJASTM Schad n Steel ni Plastic L Stainless Steel n Other <br />Grout Seat Depth (t ❑ Neat Cement {94 Ob bag3-10 gal wafer) C Sand Cement sack m W7 gal water <br />n Bentonile(20%solids) n Other <br />Grout Placement Method D Pumped U Free Fall Other C Retardant t Accelerator (name) <br />PEDESTAL Installed By Driller J Pump Contractor �_� Other <br />L, Concrete Pedestal LOimensionsr_ Width ft Length A Thick _ _. _ in I I Christy Box u Stove PiDe <br />22 -ME a Submersible_ Turbine •_: Other HP - Pump Seting (n'ti 1t BlandWater Level 1t <br />I HEREBY CERTIFY THAT 1 HAVE PREPARED TENS APPUCATION AX6 THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQWN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WITH THE CAUFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS_ <br />IT�QTAi�A 24 HOU13.Ift; <br />NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (20953-7697 <br />CC`` ` Corp Secretary -42-17 <br />SIGNED_ ,% ., TITLE p y DATE <br />■■■■■■■■Li ■i■r■■nil■■fIL'il'a■■■■■■■■ <br />ids <br />Area Q 1 q Employee4D# <br />SPECIAL Well Permit <br />❑ WAIVERReceived <br />Constructed Well Depth It <br />�m <br />a <br />O <br />F <br />rri <br />Z <br />Amount Date <br />Remitted <br />0M <br />OQ <br />Tl" <br />M <br />.Z <br />�m <br />M <br />= <br />N <br />O <br />Q <br />M <br />PE Sc Received Checkm <br />Codes Info )Cash <br />Amount Date <br />Remitted <br />PerimV Invoice f! Well lDp <br />ServfceRequest q <br />Tl" <br />I <br />Birt 4346 / r V5W� vvELL!PUMP DEntNfr <br />G30/i 2 wC/ <br />Z -d VL9£L9860Z out sielp(] eoueimnd e0Z:60 Z6 Z deS <br />