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pania�a� <br /> 00N 'IN—WE "IQ awII <br /> / V---"4 <br /> WELUPUMP PERMIT <br /> Sar JoAcrim CovwN EwRoNNENTAL HEALTH DEPARTMENT 1888 EAST HAZELTON AVEME-STocKTON CA W205-(209)468-U20 <br /> NOWREFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FRaw DATE ISSUED <br /> JOB Aouru 22851 E Milton Rd CrTylZIP Linden , CA 95236 <br /> Fine Rd 9 <br /> CROSS EEr `� APN0931100PArtcELSt�.It.9{ NDl1SEAPvucanoNli <br /> OwrRN E Solari , Andy & EdithJAL"_ ' PHONE iN <br /> OWNER A RBss 2201-5 E Milton RD CITY/sTAmmP Linden , CA 95236 <br /> CONTRACTUR Purviance Drillers , Inc PHONE 209-887-3554 <br /> iCONTRACTUR ADDRESS P O B o x 64 CITv/STATE/ZJP Linden,C a 95236 <br /> �SUBCON CTOR PHONE <br /> SUBCONTR CTOR ADDREas CITY/$TAIEILP <br /> LICENSE EXC 57 D C-61 D a09 D Other N.. 377923 ETtPfRAnON DAn 713 1/19 <br /> DOMEsnc FI r SAMPuNc:❑General Mlnaral catorm Bacteria(4391)C Dibremochloropropane(4392)7 Arsenic(4393) <br /> 1NTr. E 7 DOmeaticyPrivate 7 Inigafion/Agricultural 0 Industrial C Water Quality Monitoring D Soil SamplinglCharacredzation <br /> '!Public(Neter System <br /> 11diaeretnfrom Ormer. MderSy5t—Name Contact Nemo or Phone Numoar <br /> DRK ti New VM C Replacement Well D Well AlleratiaNMoti fication D Other <br /> D Monitoring Well(s) C ofwells :1 SDiI Boring(s) solbod.ii C Geolertmical aofbo Ras <br /> U OutOF--Service Well 7 Out-O.`-Service Well Renewal D Cross-Connection Repair <br /> n New PUMD D Pump Replacement r Pump Repair CI Raise Well Casi <br /> WELL Co TRUCTION <br /> Drilling M4 thod ■Mud Rotary D Air Rotary D Auger D Cable Tool -1 Push Point D Other <br /> J <br /> Proposed Nell Depth - bo R Excavation 14 (Y in diameter 7 Open Bottom C Gravel PadUGTavel Size in diameter <br /> D Conductor Casing in diameter f Conductor Casing Depth R <br /> Well Ca Ing Diameler 12&In Thldmess/Gauge/ASTM Sch cl .I-5b 4 Steel D Plastic C Stainless Steel U Other <br /> Grout at Depth 100C-4) a D Neat Cameni(94/b baq/5-10 gat water) if Sand Cement EA 3 sack P&W7 gal water <br /> Bentonite(20%solids) C Other <br /> Graft Placement Method •Pumped D Free Fag D Other C Retardant 1 Accelerator(name) <br /> PEDESTAL Inetatled By M Driller C Pump Contractor D Other <br /> D Concrete Pedestal(3Dimensiorts:Width ft Length ftThIck in D Christy Box 0 Stove Pipe <br /> PUMP Cl SubmersibleLl Turbine D Other HP Prang Set ft Standing Wats Level h <br /> 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. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL f <br /> WORKER,c COMPENSATION LAWS. <br /> NIMU 24 H NCE NOTICE REQUIRED FOR INSPECTIONP <br /> S-PLEASE CALL(209)953-7697 ��� <br /> srOxEo T Corpor ectary DATE12/21/17 <br /> RFc� FNr <br /> AV 0 �VFp <br /> ,04 ? ?418 <br /> VN 5 <br /> 1 �Z FP�NT UN <br /> O M <br /> e z C') 0 <br /> rr tv <br /> � ttttt� <br /> C= <br /> = O <br /> DPARTMENT SEZ O LY <br /> v <br /> Appfr 'on Accepted B Dale Area Employee ID#N&AL? <br /> Grmt Inspection By Date-7 D SPECIAL Wall Permit <br /> Pu Tip Inspection By Date I WAIVER Received <br /> In i C <br /> By Date Constructed Well Depth 7 �J ftSoil B ng Inspection <br /> COMMENT <br /> PE SC Received CheckpJ Amount PerrnlU Invoice# Well IDR <br /> Codes I ro h Remitted Service RB uestu <br /> EHD13-0(l E 1116 J1/C / WE1-L)PUMP PERMT <br /> 9'd VLSCL9960Z �/V/` out saelp(]eoueimnd e9Z:l 6 L 6 6Z oe4 <br />