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Apr 06 02 11:24p Purviance Drillers Inc <br />2098873574 p.14 <br />T, tUA 5L Lo.1 q `N `t� 1)7v— <br />VVELL1PWIP PERMIT <br />SAN JOAQUIN COUNTY =WROINMENTA- HEALTTS DEP"RTNEKr it3ri9 EJL4T HA28TON AYE ro : - STDcKron CA SS205 - (269) 451141420 <br />NOfA-RE'uNDAst E PERMIT CALL (289) 953-7697 FOR INSPECTIONS DiPIRES 9 YEAR FROM DATE ISSUED <br />JDsADnREs° Tu115' RD / C yaLirtden <br />cRDss sca r L Light Mile RA, OQ1-�&:&PARcELSM�_2�p LA.1MU5EAPPUCATrnri <br />ChWER NMIE Lawrence Sambado ___ __ P"ONE <br />OroNZ;e ADDRESS P.O. 8 o x 461 CnY/STATElZrn L i n d e n CA 99 2 6 <br />Com7tacraR <br />Purviance Drillers, Inc- PHDNE209-887-3554 <br />Cor+TRrtcrvR ApanFSS <br />P. a. fox 64 CrNJSrATFJZia Tinden, CA 95231 <br />1SvacouTKAcroR - P" <br />� <br />Susaor;TRAcroRAon4Ess 0TYIST'LTEMP. - <br />377923 7/31 /17 <br />�UcU.sE a G.;7 >_ C-611;_ 17-69 _Other NlitleFR ExwltwnoN DwTE <br />...,.a•,._...�Y Y Townshiio_ Range SelotiOn— <br />r:TOGRA 3ICAL ,VDemesliciprivate = lniga'.iandAgricyiturd : Industrial '� Wale^ Quality MnHaoring 7 Soil SampI1nplChaadeii aticn <br />i,: Puhlic <br />If tl(tfounl bum Own tri um <br />Vt'O .:er yslem a <br />�.orcaa l'Jnme cr .gone �ocr -- <br />_r- <br />TYPEOFWORK _ N.VIV✓dl _ Replacement Well '_ Vial -:. <br />ngs <br />F:.onilDting Well(s) <br />of waits Sail l3oring(s) ?of%.C"4p - Geolerhnirai ofe'� <br />Out -0f -Service Wel! O:it-OFService Weli Renewal Cra>s-Conneefion Repair <br />n,.mr, Q­m- " Raise Wel! Casino <br />WELL COYSrRuanON F <br />Drilling McC-iod -_ Mud Rotary Ai,*Rotary Rotary � Auger : Cable Tool Push Point Other E <br />Proposed Well Depth ft Excavaton in diameter _ open Bellom C Gravel Aa::d ravel Size in diameter <br />Conductor Casing in diameter I ConductoT Casing Ceolh —ft <br />Well Casing Diameler_ in ThidcnesslGavgelASTNI Schell _ Steel 7, Plastic C Stainless Steel C Other <br />GroutSeal Depin r' . Neal Cement (9Glbbagrrl0ga/water) = Sand Cement sacl+'mixl7gat ma1er <br />aniie (211% solids) 7. Other <br />�GmutPtacementmethod G Pumped : Free Fall = Dlhe- = Re1ardan1TA=e1aMtor(name) <br />PEDESTAL Installod 8, _ Driller '. Pump Contractor _ Olher <br />' Concrete Pedestat'Dimensions-VAdth R Length tl7hld; In ttChristyBoz UStovaPtpe <br />Pur.+P it Submersible-- Turbine :.l Dlher HP Pump So ft Standing WalerLevei R <br />I HEREBY CERTIFY THA- 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WnLL BE DONE Ira ACCORDANCE WITH SAN <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. i ALSO CERTIFY THAT r.Y REQUIRES) LICENSE tS <br />CORREh'T AND ACTIVE W11tH "ME CALTFORWA C0f1TRACTORS STATE LICENSE BOARD AND THAT t AM IN COMPUMCE WITH ALL <br />WORK TION LAWS- <br />NliitllMU E NOTICE REQUIRED FOR. I INSPECTIONS - PLEASE CALL (209) 953-7697 <br />S1GrrFn ��/�.e4L.rii Tm� Corporate Secretes <br />P ECEyNE <br />f <br />JOI OUIS <br />NF�'•TN DE <br />AppFcalcn Arcepled q <br />Grout Inspection BY <br />Primp Irspeclion By <br />Sot Boring Inspection By <br />CONIMENVTS <br />T <br />m <br />a <br />N <br />2096 <br />NMENTAL HEALTH <br />iMMSERVICESS <br />itpTMENT U E PNLY <br />Date <br />Area Employee IC 6�0 <br />Date <br />D. SPECIAL LNe11 Permit <br />__ Dslefo <br />D WAIVER Received <br />Cate _ <br />Const acted Well Depth ft <br />SC Received Cnect l Amount Date " , i invaice# 11 IDX <br />Gash Remitted r ServiceRewestY <br />e ^nr /P i J/"-- I A-- A Ji- I -,P -71 <br />J O 3�p�{� VY3L P.UP PERtlrr <br />'cHD cYO:C�JJ( <br />Received Time Sep. 6. 2016 4:12PM No, 1169 <br />