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L99['ON AVL!:ll LIE 'Z('unr ;Wli paAl;);� <br />WELUPUMP PERMIT <br />SAN JUAGLIN COUNTY EwmwhTENTAL HEALTH DEPARTMENT 11368 EAST HAZEL -TON AVtNUE- STOCKTON CA 45205 - (209) 4863420 <br />NON-REFUNDABLE PERMIT CALL (ZO9) 953 7697 FOR INSPECTSONS EXPIRES 1 YEAR FROM DATE ISSUED <br />.IOBADDRESs 20475 E Walnut Dr �J '/ c,n-�, Linden CA 95236 <br />[;;mss STREETN Wall Rd APN7 <br />_0 Sl�PARCELS NO USE APPLICATION# <br />OWNERNAtcrePrl Wilkins Dq <br />t <br />�T f P�ets� P„„�09-351-0502 <br />OTVNER ADDRESSL 0475 E Walnut Er Cy-NISTATrMP <br />CONMACTOR Purviance Drillers, inc. PRONE 2119-887-3654 <br />%ONTRACTOR ADDRESS P. 0. ROx 64 CrTYIyT.ATGrZJP Linden, CA 9523 <br />SUBCONTRACTOR <br />ADDRESS <br />LfCENSE GSI _ C-61 ; ° D-09 _ Other <br />PHCAFE <br />CnY)STATF/iW <br />377923 pRpmDATE 7/31 /17 <br />GEOGRAPHICALINFDR6IA17ON: COOrdinates x Y Township_ RangeSection_ <br />IUTENDED U, SF; • DomesticlPrlYate lrngat on/Agricultural Industrial = WaIlerQuaFry Monitoring =Sol Sartyling/CharaGemation <br />... frfiff c Water Sysiem <br />I Irdif<<�rntrmm Owner, awr m �mC as or ona <br />T d LIF WORK NeW Wt;11 Replacemeni Well .: inreIIAlleraIicn/Mcdification _ Other <br />Monitoring Wells) # of yells > : Sol Borin s A mEob qs Giecriechniczl 2 of boargs <br />Out-OfService Wel: - Out -0P -Service Well Renewal Cross -Connection Repair <br />New Pump i Purnp Replacement Pump Repair raj— <br />'Drilli <br />ng Method _ Mud Rotary Air Rotary . Auger _ Cable Tool _ Push Point Other <br />Proposed Well Deplh ft EacavaUon in diameter -- Open Holton :2 Gravel PacklGravei Size in diameter <br />COndVCi Or Casing in diameter I Conductor Casing Depth fl <br />Weil Casing Diameter_ in ThidcnessfGaugarASTM Schell: <br />Steel Plastic Stainless Steel Other <br />Grout Seal Depth P _; Neat Cement (9416 bags -foga! water) _ Sand Cement sack nW7 gal ymer <br />SentDoile 120% soL•ds) ' ! Other <br />Grout Placement Method Pumped -;Free Fail :: Other Retardant 1 A-1-6-1— I <br />Installed By = Driller Pump ContractorOther <br />CanemtePedestal :_Dimensions:Widlh It Lenotl <br />Cluisty Boz <br />I?IM—P 4 Submersibet; Turbine : Other HP Pump Set R �lalding Water Level O <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL HE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS_ I ALSO CERTIFY THAT WY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WITH TtiE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORSA <br />7.14aIN12411O NCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209) 953 7697 <br />SIGNE��- TITLE Corporate Secret —v - -�a-/ <br />E <br />Applicalion Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Bating Inspection By <br />COMMENTS <br />A R T M ENT USE//P�'�NNLf�LY <br />=f -Dale 3 <br />Date <br />D. C (I I Q1 <br />Dale <br />VI <br />m <br />O <br />a <br />ECEIVEp <br />JUN 12 zpll <br />HMLTH <br />AreaEmployee 00.2, j e�r6 <br />S� We Permit <br />WAIVER Received <br />Constructed Well Depth it <br />PE SC Received <br />Checidu <br />Amount <br />Permit) <br />I Codes Info B <br />Cash <br />Remitted <br />Date ServiceR equest # <br />Invoice# Well ID# <br />Q031V <br />SH 4..740 <br />¢DO1I7 <br />O/� <br />':rc1�rPUr.P Pl;7iLIIT <br />tioFQyFCIO G <br />'�pT44�MY <br />F� <br />Z'd VLSCL9260Z out saelluQ eoueiAand eZZ: L L L L Z L Unf <br />