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0S0 "`N AdWti 8l0Z LZ -2nd aulil paniaaa� <br /> WELLIPUMP PERMITR <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTV ENT 1888 FAST HAZELTON ✓AVENIJE-3 TOCRTON CA 95205-(209)45113420 <br /> NON-REFUNDABLE PEIWMT CALL 209 953-7697 FOR INSPECTIONS EXPIRES i YEAR FROM DATE ISSUED <br /> JOB ADDRESS crtY2m L i n d e n Ca 95230 <br /> m <br /> a <br /> CROSS STREET F �]APN V PARCELSUE�F D USE APPLCA'nCN g o <br /> OWNER NArAEGrimaud Farms 4Ui=aro PH e — — e <br /> OYYI'JER ADDRESS 13 2 0 s'" A Sou )3 A u r o r ab m ATT� I�cfc k o n '�r `�9 ' �T — .618 <br /> CM'TnACTOR Purviance Drillers , Inc PmeNE 209-887-3554 <br /> CONTRACTOR ADDRESS PO Box 64 c vsTA,.E0PL i n d e n , CA 9 5 2 3 6 <br /> SU6COV7RACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CnYiSTATUap <br /> LICENSE X C167 LI C-61 D 0-09 a Omer Nu%iBER 377923 EXPIRATION DATE 7/32/19 <br /> DOKESTTC WELLSAMPLWG:-General wtnelviccIforTn Bacteria(4391)L,Dibrontochlorapropane(4392)=Arsenic(4393) <br /> INTENDED USE G DomastirlPrivele Irrigation/Agricultural G industrial C Water Quality hlortitoring O Soil SanpringlCharacterizatton <br /> O Public Water System <br /> IrdReretft=OWner, WaMr Sysi mName CorMad Name W Pftane N�anba <br /> I YPE0F WORK ❑New Well C Replacement Well D Well AlleratlonlModification J Other <br /> C Mcnitaring Well(s) Xof wells G Sal Boring(s) =arbaAngs C Geolectrilcal sur oodigs <br /> n Oul-OfService Welt C Out-OfServicL Well Renewal O Crass-Connecgcn Repair <br /> C New FumD PUMP Replacement C Pump Repair O Ralse Well Casio <br /> WELL CoNSTRuCTION <br /> Drilling Method G Mud Rotary r Air Rotary 0 Auger O Cable Tool D Push Point n Other <br /> Proposed Well Deplh fl Excavation in diameter C Open Bottom 0 CTavel PacidGravel Size in diameter <br /> 0 Conductor Casing in diameter 1 Conductor Casing Depth ft <br /> Well Casing Diameter_in Thidtness/GaugeJASTM Scheid --Steel 0 Plastic ❑Stainless Steel i-]Othe <br /> Grout Seal Depth ft 0 Neat Cement(94 to Bag'&10 gal wafer) 7 Sand Cement sack rrmrl7 gal tvater <br /> Q Bentonite(20%solids) J Other <br /> Grout Placement Method D Pumped D Free Fall 7 Other 0 Retardant IAccelerator(mmne) <br /> PEDESTAL Installed By 0 Driller 0 Pump CorNradar O Other <br /> C Concrete Pedestal CDlmensions:Width N, Length fIThictc in 7 Christy Box J StovePlpe <br /> Purr P C Sutmersible Turbine 0 Omer HP ^ Pvmp Set ft Standing Wale Level It <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION ANO THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS. AND RULES AND REGULATIONS. I ALSO CEFMFY THAT BAY REQUIRED LJCEME IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT L AM IN COMPLIANCE VWTH ALL <br /> WO CO SAT10N <br /> MINI 24 NCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL <br /> � 1 l (209)9537 <br /> T. orporate Secretar3�TGL <br /> VED <br /> I <br /> '13 <br /> t z 2018 <br /> LL ilk 11: <br /> ENTAL HEALTH <br /> I SER�CES <br /> r <br /> t <br /> EP RTMENT U E O <br /> Application Accepted By Date Area EmplayeJe ID#_������I� %90 V <br /> Grout Inspection By Dale Cl SPECIAL Well Perrnit ��yGti C <br /> Pump Inspection By DateD WAIVER Received A9 d <br /> Soil Baring lnspection By Date Constructed Well Depth ft a <br /> COMMENTS <br /> PE SC Received Checkff Amcunt PermiN <br /> Co Into Cash Remitted Date Service Re nest# Invoice* Well i[ <br /> kV—j Z 'POO -7a3 <br /> EHD<J.:Y 1171/16 �V=_1.1PL'IIP PeRNli <br /> Z'd bL9£Z2860Z OUB SleIIiaQ GOUelAAnd dZ I,:bO 8l ZZ 6ny <br />