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tilZti '°N WdSZ ti 11 C ��� auall pania�a� <br /> VVELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY E10MIONMENTAL HEALTH DEPARTMENT 1868 EAST HAM-ION AVEMIE-STOCKTON CA 9$205-(209)468.J42o <br /> NON-REFUNDABLE PWWIT CALL 209 953-7657 FOR INSPECTIONS EXPIRES'I YEAR FROM DATE ISSUED <br /> Joa ADDRESS ` <br /> fuu E Frazier Rd 07YIF2�P Linden 9. 36 <br /> CROSS sl d 1.e m e n t s Rd APN / PARCEL <br /> S12F& LANG IlSE APPLICATION?'. a <br /> an,NsrN,..,,ER J Co Sti0Zi010 PHaNE209-351-0078 <br /> N <br /> iOwNER AOOREss7 300 N Fine R d CrrrISTATEraP Linden CA 95236 <br /> 'CONTRACTOR Purviance Drillers , Inc PHOM6 209-887-3554 <br /> CONTRACTOR ADDRESS PO Box 64 CIn.IsTATFIz pL i n d e n , CA 95236 <br /> SUBCONTRACTOR PHOCE <br /> SUBCONTRACTOR ADDRE55 CrrvISTATFJZP <br /> LtcrNSE u csl ❑D a9 ❑otherNut,aEA 3 7 7 9 2 3 EXPIRAMON DATE 7 J 31/19 <br /> OomESTtc WELLSAiNPLING:C General MineraVColifotm Bacteria(4391)E Ditimmochloropropane(4392)_Arsenic(4383) <br /> INTENDED UsE D DCDlezlidPrivale InigationlAgrictrtural C Industrial C WaierQualilyMonitoring D Sal SampingJCharacterizaUon A11 <br /> ❑Public Water System <br /> Irdurerentrrulri Owner. WalerSislem Name CcMza Nara or Phone Number <br /> rrnEOFWORH D NmxWeJ C Replacement Well D Well AfteratlonJMorlificalion C Other <br /> G Mmtileirg Wells) AOf wells C Sail8cing(s) vol Donogs r GeolecMlaW 3erbor ngs y��9 O <br /> Out-0OrC OutO`Servo Well Renewal ]Crus-Connection Repair 1/ r <br /> D New Pump &Zrry Replacement C�PLMp Repair 0 Ralsa Well Casing <br /> WELL CONSTRUCTION 'O�Q 2o'R <br /> Drilling Method 0 Mud Rotary r'Air Rotary U Auger D Cable Tool -I Push Paint rt Ot7Ler •v 'l COU VV <br /> Proposed Well Depth ft Excavation in diameter C Open Bottom C Gravel Paclr/GraveJ Size T FNTq N>]. <br /> ❑Conduclor Casino in diameter / Conductor Casing Depth a T A <br /> Well Casing Diameter_in ThirY.nass/Gauge/ASTTA Sched =Steel 0 Piaac 17 87ainless Steel 0 Other <br /> Grout Seal Depth tt 3Neat CPment(94thbagrSiOgal cwale4 0Sand Cement sack m&17gdwater <br /> C Bentonite(20%solids) :1 Other <br /> Lout PFacenient Method 0Puruped G Free Fall 7 Other D Retardant/Acceleratcr(name) <br /> PEO ESTAL Instalted By C DrCer 7 PUMP Contradar C Other <br /> 0 Concrete Pedestal CDlmensibns:Vwidth R Length R Th!rk to ,Ghristy Hax ElStove Pipe <br /> PUMP 0 Submersible urbine D Olner HP O Pump Set ft Slanding Water Level A <br /> I HEREBY CERTIFY THAT I ROVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGUt.ATTONS. I ALSO CERTTFy THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTP/E WNTH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS <br /> MINI M 24 HO DV E NOTICE REQUIRED FOR WSPECT[ONS-PLEASE CALL(209)953-7697 <br /> SIGN n�orporate Secretar&,E <br /> � I f <br /> ECEIVEC <br /> OCT 0 4 2018 <br /> VIRONMENTAL HEALTH <br /> iI a I PERMIT/SERVICES <br /> I i <br /> I <br /> D R MENT U E OLLY �[ <br /> Application Accepted By le d /`� Area G Ern0ayeeID# <br /> Grout Inspection By Cale PEcI Well Permit <br /> Pump Inspection ByA�R40� 1,11 0 ffVJAA 1�Date 1C1 1 2 to -1 WAwER Received <br /> Sal Baring Inspectian By Date Constructed Web Depth ft <br /> COMMENTS <br /> PE SC Received Chec1-7 Amount Date Porrnitl Invoiceg Well IDN <br /> Into .. _-- h _. emitted S ice <br /> EHD 4acs BOVIG �l ,Y-_1 Rurp FE 1.117 <br /> �Z'd bLSU9260Z U out Sa811!.la aouelAind dZq:Co 9 Co 100 <br />