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ZED "N 066:k 91H '0l';10 ami j paAI;D;� <br />WELL/PUMP PERMIT <br />SAN.)oAOum Coupw EMM)RONNENTAL HEAL-mDrPARTAENT 1e6REAs7rHAzELTaNAvEhwz-STocxroNCA45M - (249)4GM420 <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS L-"IKtS 7 YEAR 1 -RUM LATE 1S,UEU <br />JOB ADDRESS 81 5 0 N Duncan Rd ciTYtma L i n d e n CA 99236 <br />I <br />nogg STnEET � APN PARCrLSIM LAND LIST APPLICATION9 <br />OWNER NAM Doug 17 enrezz.g. PHo,E 209-3.51-0241 <br />OwM3t AoDREsz 815 0 `N D u n c a n Ed C"Y/SrrATSZ8 L i n d_e n CA q5-216 <br />COMMACWR Purviance Drillers, Inc PHONE 259-897-3554 <br />,.--A-- ­ is 0 Box 64 c,n ISTA,e z,PL i n d e n, C A 9 52 3 6 <br />PHONE <br />)R ADDRESS CMISTAWMP <br />C-57 U C-si -I D-69 0 Omer NUMMR 377923 WwATION DATE ? ' 31 ' 19 <br />[)ovEBTICWELL SAmpuw: C General MineraUCaffarn Bacteria (4391) G Dihratnochlompfopane (4392) = Arsenic (4393) <br />IN»rm¢ouss 1p0cmestictPliTwe r5 Irrigation/Agricultural G industrial D Water QualityMonitaring O Soil SamplIngtCharacierization <br />e Public water System <br />Imwereol fmm Croner 6Yaltrswi mKane Conaa Narre or Pnare HunCer <br />TYPE OF WORK 0 New WWI C Replacement Well D Well AtteraWMFMo?ifiralion 3 Other <br />0 Monitoring Wetl(s) #afrrdls G Soil Bming(s) *°moue's G Geotechrilcal 1 =ar6ar ngs <br />O Out -O( -Service well �C.! Out -Cf -Service Well :1u <br />Crs-Cenneclion Repair <br />0 New Puma C Pump Rep�A ment Pump RepairJ3 Rake Well Casing <br />Driiling Method O Mud Rotary r Air Rotary O Auger O Cable Tool 7 Push Point ❑ Other '- <br />Proposed Well Depth It Excavation in diameter 3 Open Botlorn IC Gmvet Pack/Gravel Size in "W ter <br />0 Conductor Casino to aameW / Conductor Casing Depth ft J <br />We►I Casing Diameter _ in Thidmess/Gauge/ASTM Srhed - Steei 0 Plastic Lr SIsInhw Sleel 0 Other N <br />Grout Seat Depth A 0 Neat Cement (94 Ib bag3r0 go/ nafel) D Sand Cement sack <br />0 Bentonite (20%solds) 7 Other <br />GrautPlacement Method 0 Pumped 0 Free Fal) 7 Other 0 Rehudent/ACCeleralor(name <br />PSMSTAL InsUlied By 0 Dn11er 7 Pranp Contractor ❑ Olher <br />13 Concrete Pedestal CDlmenslons-Wltlth ft Length rt Trflck m -1 Christy Box 7 SlD+re Plpe <br />PUMP Slbmerable❑ Turbine 0 OLner HP Pump Set fl Standing 1Water Level R <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN CGLWJiY 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 AAO rN COMPLIANCE WITH ALL <br />WO,It PENS ON LAWS. <br />MIN M 24, ji0,1LI A f ANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (2091953-7697 <br />staNen ­57--cf- n,�orporate SecretaraA,,A!) <br />w <br />a <br />z <br />1 ? ?418 <br />�oMEHTa NAY <br />TH <br />EPA TMENT U E NLYA <br />ApplicatidnAccoptcdBy Date Area ` Employeell]S.� <br />Grout Inspection By Date 0 SPECIAL VV011 Permit <br />Pump Inspection By MQ,C& 4;1&00� Q � Sie 1L 1 1 1 n ❑ WAIVER Received <br />Soil Boring Inspacfion By Dale Constructed Well Depth fl <br />COMMENT'S <br />Z'd tZ9£L9960Z out saallua eoueiAand azo:6 L 91 0l 100 <br />