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ti6Ll 'ON 06ti:01 LM '0E 'ung MI J paAl;�;� <br />' WELLIPUMP PERMIT <br />SAN JOAOWN COUNTY EmnRONntENTAL HEALTH DEPARTl%!SN'T 1868 EAST HAZEL -TOM 01VENUE-SMM-r11 CA 9S7nr - I7r141 ncc_z��n <br />NUN-KEFUNDABLE PERMIT <br />JOB ADDRESSLive <br />1 0 <br />L <br />CROSSS7M!Her E i V e <br />OVVTJER NAME H A T e C T, 1. <br />OUNER ADDRESS 1 1 8 S 7 <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />CALL (2 <br />N Alpine Rd <br />Oak oom,;hj <br />9$$-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br />.{�� cn,§tockton CA <br />50-t-2- 0 PARCELSIZE LAND USE APPUCATION; <br />►UAD ,-_. 24o209-481-8981 <br />Purviance Drillers <br />P. 0. Rox 64 <br />LICENSE C•7 _ C-611 D-09 <br />Inc. <br />PHaHE 2n91-887-3554 <br />Crrr1STATrJZP Minden, CA °523 <br />PHONE <br />CITY)STATFIZIP <br />NUMaER 3 7 7 9 2 3 EXPIRATION <br />7/31 /17 <br />wcwr [u LnarORArAT1WS: GDOrdinates X Y Township _ Range Section_ <br />INTENdEO USE 0 Damestc/Private -. lrTigalionlAgricubirat _.Industrial - Water Quality Monitoring -�, Sad Sampting/Charactmzali n <br />Publt VVWer Sys:ery <br />IC tl:Ren: r0. hvm Owner. aier y5 m me � air ar one unuer <br />TYpEOFWoREc _ New We! ReplacemenlWell We11AReratiDNModifiralion -: Other <br />MonitoringWeN(s) rofwells S01160rSng(s) solnonngs r Geotechnical 4u7Eonngs <br />Out -Of -Service Wen Out-OFSemice Well Renevrai _ Cross -Connection Repair <br />-' New Pump W Pump Replacement Pumo Repair - I�ateoinreu rte..:..., <br />i <br />Drilling Method Mud Rotary _ AirRolary Auger _ CabfaTcol _ Push Point _ Other <br />Proposed Well Deplh fl Excavation in diameter _ Open Bottom _ Gravel PaWGravel Size in diarneter <br />Conductor Casing in diameter f Conductor Casing Depth ft <br />Wall Casing Diameter in ThicknessfGaugPJASTM Schell Steel Plastic q- Stainless Slee Othe <br />Grout Seal Cep W P � Neat Cement (94)b bagIS-10 gal wated Sand Cement sack rrik(7 gal water <br />Bentonite (2056 solids) ! Other <br />Grout Placement Method -Pumped - Free Fall_ _ Other r Retardant I Accelerator (name) <br />PEDESTAL Installed By Drller Pump Contractor Other <br />Concrete Pedestal _Dimensions: Width P, Length n Tick in - Christy Bor u Stove Pipe �I <br />PuM� 4 Submersiblat, TurNne is Other HP Pump Set n cr Water i <br />Ft <br />I HEREBY CERTIrY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL. BE DONE 1N ACCORDANCE MTH SAN ' <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERMF;y THAT MY REQUIRED LICENSE IS <br />C T AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE 130ARD AND THAT 1 AM IN COMPLIANCE 1NST)t ALL <br />WORKER MPENSA <br />N (URI] H VAiUCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 9 <br />SIGNE TITLE Corporate Secreta qy , /7 <br />Application Accepted By <br />Gmul lnspec er. By <br />Pump Inspection By <br />Soil Boring inspection By <br />COMMENTS <br />TME NT USE NL1 <br />Date <br />Date <br />r <br />Dale <br />I <br />Date <br />m <br />D <br />0 <br />m <br />w <br />Area Emle'ayee lOR' P1,11-0 <br />'SPEC:IikL Well Permit <br />D WANER Received <br />Constructed Well Depth ft <br />at <br />:J3na &XI"463UD I-'-lcLL fvUf.P PERt.!IT <br />012 li 1-b <br />Z'd VZSUIRH0Z <br />X <br />1M <br />om" <br />T <br />• ■ <br />M <br />0 <br />OUB Saajji_IQ GOUeiA.lnd la-L9:OL Z L 0C unf <br />PE SC Received <br />Codes Info Bye <br />ChecklW <br />Amount ( Q <br />P,emltled <br />6 Fe. <br />Pertn1N <br />Service Fepuest, <br />Invoice# Wall IN% <br />43116450 1/,W t <br />5�ash <br />1/�5� <br />r <br />1 7n_`�Il <br />rkifl1,W4 <br />STI <br />Wp1)n-;10Aw <br />at <br />:J3na &XI"463UD I-'-lcLL fvUf.P PERt.!IT <br />012 li 1-b <br />Z'd VZSUIRH0Z <br />X <br />1M <br />om" <br />T <br />• ■ <br />M <br />0 <br />OUB Saajji_IQ GOUeiA.lnd la-L9:OL Z L 0C unf <br />