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0811'°N WdW8 L101 '81'2ny awil pa�a)a� <br />EIf <br />all WELL/PUMP PERMIT <br />SAN J OAQUIN COUNTY EmnamPIENTAL HEALTH DE?ARTMENT 1666 EAST HAZELTON AMEN uE - STom-roN CA 95205 - (209) 466-3420 <br />NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS t;API KtJ T YEAR FROM UATE tSSUEU <br />Joe ADDRESS 6747 N Wal1Rd c1TYlzlp Linden CA 95236 <br />CROSS STREET Hwy 26 APN 3O 9 PARCEL SIZE LAND Use AppuCAnou # <br />OWNER NAME Lee Metzler FArming ITEC GWY��OHa,99-986-9320 <br />OWNER ADDRE356 7 4 7 N Wall Rd/7D Sf N• a tef- crr~jsTAwjzpL i n d e n CA 95236 <br />CONTRACTOR Purviance Drillers, Inc. P.209-887-3554 <br />CONTRACTOR ADDRESS P• O .Box 64- CrTYISTATWZIP Linden, CA 95236 <br />SUBCONTRACTOR PHOUE <br />SUBCONTRACTOR ADDRESS CIT7ISTATE/ZtP <br />LICENSE K c-57 .. G6T 0-09 J Other NUMBER 3Z92-1-- F-xprRATION DATE 7 / 31%L9— <br />GEOGRAP141CALWFORNAMON: Coordinates X Y Township_ flange Section <br />lm-rmcED USE DomestidPrivale InigatimdAgdcultural D Industrial ❑ Waler Quality Monttoring 1] Sail Sampling/Charaderizaticn <br />_ Public Water System <br />H d(rleren! hoes OWA![ a r )sem Kiamo WW a, one MmDer <br />TYPEOFWORK _. New Well _ Replacement Well L Well Alleratton/ModRcatlan :i Other <br />Monitoring Wells) 4 o sells r: Sol Borings) sOr h0 N' F Geoleclnical rior oorings <br />Out -Of -Service Wdl n Out -Of -Service Well Renewal n Cross -Connection Repair <br />Net" Pump Pump Replacement ❑ Pump Repair " Raise Well Casinp _ <br />W ELL CONSTRti CION <br />--Drilling Method L-- Mud Rotary :.. Air Rotary _ Auger Cable Tod J Push Point t. Other <br />Proposed Well Depth fl Excavation in diameter ❑ Opel Bottom G Gravel Pack/Gravel Size n diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />jWell Casing Diameter_ in ThieknesslGaugeJASTM Sched i'! Steel : Plastic Stainless Steel L; Other <br />Grout Seal Depth ft u Neat Cement (94 lb ba -W&10 gal water - Send Cement sack r7Yx/7 gal vrater <br />11 Benlonite(20%so@ds) R Other <br />Grout Placement Method a Pumped G Free Fall - Other ❑ Retardant /Accelerator Inane) <br />PEDESTAL Installed By " Driller Z Pump Contractor G Other <br />. Concrete Pedestal L Dimensions: Width it Length ft Thick in i.! Christy Box U Stove Pipe <br />Pump �a6ubmersiblej(Turbine , Other HP Pump Set ft Standing Water Leve ft <br />I HEREBY CERTIFY THAT I 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_ t ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br />WOR 12$ COMPENSATUd WS- <br />/ <br />Mf UM H RN) <br />DVANCE NOTICE REQUIRED FOR INSPEC7EONS -PLEASE CALL (209 76 7 <br />s,3N ' Tn>ECor Secretary D. �7 <br />ztil�i <br />Received <br />By <br />OMNI <br />4 <br />II ��.5,L <br />X11 <br />MEE <br />d 1 WT `- 132 <br />..■I <br />■■■I <br />.... ..1 <br />M.■I <br />MENI <br />OMNI <br />MEE <br />MEE <br />Application Accepted By <br />Grout inspection By <br />Pump inspecton By <br />Soil Boring inspection By <br />COMMENTS <br />ARTMENT SE NLY <br />Dale 30 0 <br />Date <br />Date <br />- trilw1ov- <br />Dale <br />_m <br />D <br />0 <br />0 <br />0 <br />84 9 <br />sr <br />QV/N <br />FNMENCOVN� <br />P". Te , <br />Ares -`�i Employee IDX l� <br />❑ SPECIAL Wen Permit <br />❑ WAIVER Received <br />Constructod Well 13vpth It <br />PE SC <br />Codes Info <br />Received <br />By <br />Check#1 <br />Cash <br />Amount PormiU Invoice ti Well ID# <br />Date <br />Remitted I Service Request# <br />II ��.5,L <br />d 1 WT `- 132 <br />EHD43-W <br />4/30112 <br />WELLIPUMP PERMIT <br />Z'd VL5£L9860Z out saellij4 aoueinand d�0 �0 L L 8Z 5ny <br />