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• BWIN OW1 8[OZ 'lp2ny awil paAI;3;� <br />WELUPUMP PERMIT P <br />SAN JOAQUIN COUNTY EWARONMENTAL HEALTH DEPARTMENT 1868 EAST HAZE' TOM AVENUE - STDC%TON CA 95705 _ 17na%�rt_•� en <br />RECEI <br />AUG 31 <br />s <br />k4 Uri -KEFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 'I YEAR FROM DATE ISSUED <br />JOaADOREssl742 E Comstock Rd /- 1 CrYrwpLinden CA 95236 <br />CROSS STREET D u ri c a n Rd APN � 19 7 O PARCEL SUE LANs Use APPucnnoN # <br />OWNERNAm£ Lawrence Sam PiotZ09-931-26R <br />OWNER ADDRESS p - 0 - 1-3.o x 4 61 O CrTYfsTATFJa;l i n d e Ti C A 9 5 2 3 6 <br />CONTRACTOR Purviance Drillers, Inc PNoNE 2()9-887-3554 <br />'CONTRACTOR ADDRESS PO Box 64 CRY,sTATEmp L i n d e n, C A 95236 <br />SUBCONTRACTOR PNOf1E <br />SUBCONTRACTOR ADDRESS 0TYiSTATE21P <br />LICENSE 'K C-57 D C-61 ❑ D-09 0 Other NUMBER 377923 ExptRanoN DATE 7/31/19 <br />..-� aLJNMYL1Nli: U uenerai mineralfuclllorIn Bacteria (4391) - nihmmnr-hlnrr.nrnne„n Lnaoo- <br />'NTENOED USE D DomestciPrivate W Irrigatfon7Agriouturaf C Industrial G Water Quality Monitoring ❑ Soy I SamplingrCharacterization <br />C Public WaterSystern <br />If tiMerent hmtt Own- water System Name wn!act Name or Phone Nurturer <br />_r -- .. _,. .. .vcrrivrat--wiwomirmation ] Other <br />0 Monitoring Wel(s) tl of vmjs a Soi; ecTing(s) AofhOfngS D Geotechnical a of boringis <br />U Out -OI -Service Well u Oul-O{-Service Well Ree—r o.,....:- <br />- <br />11 New Pump Pump Replacement j Pump Repair ❑Raise Well Casing <br />W5Seal <br />IDNl _ <br />D0 Mud Rotary i_ Air Rotary 0 Auger El Cable Tool .0 Push Point ❑ Other <br />PrDepUT R Excavation in diameter ❑ Opert Bottom G Gravel PacidGravel Size in diameter <br />O Conductor Casing in diameter / Conductor Casing Depth R <br />Diameter_ fn ThicknessfGaugefASTti SThed Steel 3 Plastic O Stainless Steel D Other <br />Depth tt ❑ Neat Cement (941b bagf5•10 gal uelet) 0 Sand Cement sack 17TW7 gal Water <br />D Bentonite (20%solids) 7 Other <br />Grout Placement Method 0 Pumped ❑ Free Fall :) Other 7 Retardant/ Accelerator (name) <br />o— <br />-- - - - _- -7 „ " - � rump wnraaor ❑ Other <br />❑ Concrete Pedestal COfriensiorw V.14ph ft Lennrh <br />P!Mv 0 Subme sibl urbine ❑Other HP Pump Sel ft Standing Wafer Level N <br />HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCELICENSE IS <br />WITH SAN <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS, I ALSO CERTIFY THAT M <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN Y COMPLIANCE REpUIREO ED WITH ALL <br />WORW,:tSGQ1HIPENSATION LAWS <br />ApPtication Accepted By <br />Grout lnspection By <br />Pump Inspection By <br />Sol Boxing lnspecltnn By <br />COMMENTS <br />CE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />r,f. orporate Secretary,,, f% V/ ' <br />DEP 0. R T N E N T U$ E Y <br />Date -&3ar Area-`�� �--`- Employ- 10* <br />Date IF ❑ SPECIAL Well Permit <br />I Date 'l WAIVER Received <br />Cam Constructed Well Depth R <br />Z'd tzsczge60Z <br />WEL' /PUMP PER?AIT <br />out saallu4 eoueifund e0Z:80 96 6C 5ny <br />