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A]_pi <br />BOO "N Ad9ti:9 8102 , [ � 2ny auJil paA ;);a� <br />WELUPUMP PERMIT t' <br />SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTNENT ime EASTHA7n ToNAvENUE-STocxTaN CA952D5 - (209)468-3420 <br />NCN-REFUNDAELE PERMIT CALL (2091953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE lssUED <br />JOBADRES 8650 <br />6 5 0 E Handel dow2lP0di CA <br />sS�eMETAlpine Rd APN Uy, 'Pt PARCELSLZEL8 tn 2ANn 95240 <br />USE APPucATtoN <br />DITNER NArnE Jack & Lynn G r U n S k y T m n -1-<'I 1 1_ Lr/�1A M C;�pt, T <br />t`2 �9-471-5917 <br />OWNER ADDRESS py -Box 17 1 <br />§zs-q) -) Z.YiS A CA 95258 <br />CONTRACTOR Purviance Drillers, Inc PHONE 209-887-3554 <br />CONTRaeroR ADDREss PQ Box 64 Crry STATFJIJA L i n d e n, CA 95236 <br />PHONE <br />'SUBCONTRACTOR ADDRESS CfMSTATEJ21P <br />LICENSE X C-57 Li "1 0 D -M ❑ Other NUMBER 377923 EXPIRATION DAIS 7/31/19 <br />DOYESnC WELLSAWL1NG:I: General Mineral/Calitarrn Bacteria (4391) _ DibromocJTforopropane (4392) -- Arsenic (4393) <br />aPei oywem <br />Ifcil(erenl rom Ovmer. Water System Name <br />- -- - "'....-, u—11wtera<ioronnoolncatlon O Other <br />C Monitoring Wells) AOf vANIs C Soil Boring(s) A°f DorLvs n Geotechnical a°fbaff.gs <br />G Out -Of -Service Wel C Out -Of -Service WeJI Reneval O CrOSS-Cennection Repair <br />0 New Pump C Pump Replacement W Pump Repair O Raise Weal Casino <br />Drilling Method O Mud Rotary r Air Rotary O Auger O Cable Tool 0 Push Point n Other <br />Proposed Well Depth ft ExcavaUcn in diameter - Open Bottom g Grave[ Pack/Gravel Size in diameter <br />U Conductor Casing in diameter I Conductor Casing Depth ft <br />Well Casing Diameter_ in ThidmesslGauge/ASTM Schad = Steel ❑ Plastic C Stainless Steel J Other <br />Grout Seal Depth I, U Neat Cement [94 fb Dagf510gat V ajar) r Sand Cement sack mixt) gal vrater <br />C Bentonite (20%solds) O Other <br />Grout Placement Method 11 Pumped O Free Pall 7 Other 0 Retardant/Acc(9Pralnr1-% <br />PEDFSTAL Jns-talfed By D Driller 0 Pump Contractor 7 Other -' <br />0 Concrete Pedestal CDlmenslons: vtrdlh R Length ft Thickin Christy Boz :J Stove Pipe <br />PVMP Al SubmerslbleD Turbine ❑ Other HP Pump c rfl Standing Water Level fl <br />I HEREBY CERTIFY THAT I HAVE Pa THIS APPLICATION AND THAT THE WORN WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY ORDINANCES, STATE t -AWS, 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 J AM IN COMPLIANCE WITH ALL <br />WORKERS66MP NISATION LAWS <br />APPlicattOn Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Sail8onng Inspection By <br />COMMENTS <br />EHO43-W PAI/15 <br />Constructed Well Depth <br />%%S4-- rwMP PE; wT <br />0 <br />0 <br />a <br />I� <br />w <br />E <br />GEIVD <br />V'd VZSCZ2260Z out s)elp(] eoueiAand e0Z:809L L£ bnV <br />