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L606 "N WdS1 :E L106 'Sl '2ny atoll paAiaaa� <br /> t I G...�. WELUPUMP PERMIT r <br /> SAN JOAQ14M COUNTru4MoNWBMTAL HEALTH DEPARTNENT 1868 EASTHAZEI_TON AVENUE-STOCK70M CA 95205-(209)488.3420 / <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOSADOREsS 7300 N Fine Rd ct,y?,PLinden CA 95236 m <br /> cRosss-imuComstock Rd APN 091x.3009 <br /> a <br /> C <br /> PARCELSIZE \ LAfID LLSE APPo.ICgT•DN is <br /> AIM.. z <br /> ERNAME R.J. Costigliolo ,,,,,xr209-351-0078 m <br /> OMER ADUREss 7300 N Fine Pd CrsYASTAT,,,,, 'i n d e n CA 95236 <br /> CONTRACTOR Purviance Drillers, Inc. _ 209-887-3554 <br /> CONTPACTOR ADDRBSs P. 0. z3 o x 64 CITYIS-rA,�� Linden, c k X3 5 2 3 <br /> SUSCONTRACTOR PHONE i <br /> SUBCONTRACTOR ADDR:Ss CITYISTATFIAP <br /> Lfcrose 0 C-57 C-61 1;0.09 Other NUMBER 377123 EICP,... DATE 7131 /1q <br /> GEOGRAPHICAL INFORATA-OON: Coordinates X Y Township_ Range Section_ <br /> ([aTFNDE — ®DomesbciPdvale 'InigatiorvAgriouttural L:Industrial 7-Water Quality Noniloring 'Soil SampiinglCt a cter¢aBen <br /> Public Water system <br /> 1141demnt fromow . er ys m me on arnc ar ane omoe� <br /> TYPE OF WORK _New Well L Replacement Well ":1 1Nell AlterallofflModificaton Olber <br /> Monitoring Weu(s) s Of vlall5 Soil Baing(s) Ro1°O"''m r >orboi4gs <br /> r Gecterhnical <br /> "!Out-OfSemko'Nell -Out-Of-Service Wen Renewal -1 Crass-Canneclion Repair <br /> Naw Pum aPumP Replacement Pum Re air _Raise Weil Casing <br /> WELL CON53BUC710M <br /> Drilling Method -Mud Rotary -Air Rotary ..Auger _Cable Tool -Push Point _ Other <br /> Proposed Well Depth R Excavation in diameterOpen Bottom -Gravel PacWGravel Size in diameter i <br /> Cor Casing in dameler A Conductor Casing Depth ft <br /> Weil Casing Diameter <br /> in ThidrnesVGaugeIASTM Sdhed :]Steel Z Plaster_ =Stainless Steel E:Olher <br /> Grout Seat Depth it O Neat Cement(941b badSlOgal Iva" _Sand Cement —sack mxrA gal dater <br /> "-Bentonlle(20%solids) Other <br /> Grout Placement Method =Pumped Free Fan -Other1 <br /> Relardant l Accelerator(nerve) <br /> PEDESTAL Installed By _CnIler Pump Contractor Other <br /> _Concrete Pedestal:_Drmsncions:tNdlh ft Length It TWc to _Christy Baur Stove Plpe <br /> eA-- iqpSubmersibleu Turbine Other HP Pump Set ft Slandrtg Weer level R <br /> I HEREBY CERTIFY THAT 1 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 WMi ALL <br /> W COMPENS. �LA . <br /> I 1MU DVANCE NOTICE REQUIRED FOR 1hlSPECTlONS-PLEASE CALL{209)953-7697 <br /> Sl D TITLE Corporate Secret ,r,y 5-/S-17 <br /> i <br /> Q dl <br /> 1 1 <br /> W C�: LU <br /> N 5 ' <br /> f <br /> L[771 1 <br /> f- W <br /> i <br /> V CD , PAY <br /> W Q 1 RFc�vNo <br /> W <br /> - <br /> FT <br /> of" E4-r, <br /> EP R T M ate U N L Y *ECIAL <br /> APPl�ion Acrxpted BY" Date ataFJnployee tI�iE�a�Grout Inspection By Date Well Permit <br /> Punp inspection By Dale a WAIVER Received <br /> Soo Bering Inspection By Date Constructed Well Depth tt <br /> COMMENTS <br /> PE SC Received CheckW Amount Permit — <br /> Ccdes Info B Cash Remitted Da�m Servlee Re nest C Invoice# Well IDft <br /> 040_P <br /> W I <br /> EHD 4306 y <br /> Tr]rVt'-' nz�/ waa.LIRnti PERLin <br /> £'d bL9£L8860Z out saajji.lQ eousin)nd dZ6:£0L1,91, 6nV <br />