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I <br />ltitiZ'°N W0:01 L106 '6[ ';)0 IWIJ paAia°a� <br />WELUPUMP PERMIT Z <br />SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 FAST HAZELTON AvENUE - ST OCKTON CA 95205 - (209)4683420 <br />I1dvn-KthUNDA13Lt PERMIT koALL (LUy) VOJ-/b9/ FOR INSPECTIONS tJCPtKt5 1 YEAR FROM DATE ISSUEE <br />JOB ADDRESS 16455 7Comstock <br />� o m s t o c k RdLD <br />j CITY/z1L - n Ca 95236 <br />CROSS STREET T u 11 y R d APN O `� I G �S� ! PARCEL SIZE ± -.`� LAND USEAPPLICATION R <br />OrtNERNAMELaWrence Sambado PHDN209-931-2568 <br />OvinuR ADDRE59P . 0. Box 461 cImSTATEmpL i n d e n Ca 95236 <br />CONTRACTOR Purviance Drillers, Inc. PHO209-887-3554 <br />CONTRACTOR ADDRESS P. O •Box 64 c,,,IST,,,j jp Linden, CA 95236 <br />SU13CONTRAC0A <br />PHONE <br />SUBCONTRACTOR ADDRESS C TYISTTATEIZIP <br />LJCENSr A. C-57 ! : C-61 0-09 ;; Other NUN®ER a / 7 7 23 EXMRATTON <br />GEooRAPmxALINFORMATMW: Coordinates X Y Township, Range Section <br />NTENDEO USE ;] DomesiciPrivale ? Irrga[ion/Agficdtural !industrial 0 WalerQuality Won -doting -'Soil SampfinglCharaclerimbon <br />_ Public Water System <br />If dilwenl from Own_(. wime, oys em > o arra ar one u r <br />TYPE OF WDRK L New Well Replacement Wel L Web NIeration/MDdifiralion _, Other <br />M Monitorng Well(s) #o wells : ; Soil Boring(s) *of fi0itrwjs r Geotechnical <br />Out -Of -Service Well 1; Out -Cf -Service Well Renewal F Cross-Conneclim Repair <br />IF of bad <br />Drilling Method PAud Rolery Air Rotary ! Auger I Cable Tool ! Push Point 1_: Other <br />Proposed Well Depth It Excavation in diameter L Open Bottom C Gravel PacklGraveJ Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth it <br />Well Casing Diameter_ in ThicknesslGauge/ASTM Sched Steel L Plastic Stainless Steel C Other <br />Grout Seal Depth R - Neat Cement (94 1b bag/5-10gai v aJer) _ Sand Cement sack mlxr7 gal water <br />-Bentonite(20%solids) Otho <br />Grout Placement Method L Pumped Free Fal F- Other _ Retardant (Accelerator (name) <br />PEDFBTAL Installed By Fl Driller 7- Pump Contractor f� Other <br />:: Concrete Pedestal LDlmensionsr Width H Lengthft Thick in 1! Christy B*. a Stove Rpo <br />PUMP S Submersibleu Turbine , Other HP Pump Set 152Standing Wa'er Level ft <br />1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE JN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I 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 <br />woRKERS CM*R�NSATION LAws. <br />\ MIN104 24 HOS NCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-76 7 <br />slaty®�_ :��� %i" - (,,Corp Secretary oA,E /7 <br />PAYMENT 1 i I t , <br />RECEIVE <br />T DEPARTMENT USE ONLY <br />aC1 6 2A%D1icati0n Accepted By Dale <br />u 1 �QU� COUg" Grout Inspection By Dale <br />y N IOIR,TNME�AI P <br />F� ump Inspection 3y Date <br />„c h Sol Boring Inspection By Date <br />COMMENTS <br />Mn <br />�a <br />m <br />Area G/ Employee IEW ' 1� <br />`J SPECIAL Well POrMit' <br />El WAIVER Received <br />Canstrucied Well Depth ft <br />PE <br />Codes <br />SC Received <br />Info a <br />Check#/ <br />Cash <br />Amount Pennitl <br />Remitted I Date Service uest# Invoice it WeAlO# <br />Z,D, L� �dQs�7J <br />413W12 <br />£' d VL9£L8860Z <br />WELL,PUNP PERMIT <br />out sl9jji.l4 aoueinlnd 1300:0L L L Z L 100 <br />