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lHl "N Ad9�:N WI 'cl 'Jlo sold paAl;3;� <br />WELVPUMP PERMIT <br />SAN JoAOUINCauNry ENViRcNmErjrAL HEALTH DEPARwLBvT I115B EASTH-TON AVENUE -$7ocKwN CA 95205 - (209)46&9420 <br />IV U111-Mbr-UNOAB r' MZK% T <br />I.HLI- ka <br />A DORESS <br />Z'S'5/�jE� <br />1"I % l -l-on k <br />IJOB <br />iv <br />1'2 <br />%/1C,'� <br />�f APN� <br />(CnassSTREErr <br />OWNER NA14C <br />❑ WAfvER Received <br />Ib <br />e <br />1CwNER AooREss <br />22015 <br />7"1/ % e <br />ft <br />Purviance grill <br />�CQTMACMR <br />CafrnzAcmR Ao Mwss PO <br />BOX 64 <br />)R ADDRESS <br />CS7 D G-61 7 D -(L ❑ <br />yDJ-IO`Jr F0R1N5PEGT1VNS tJCY1KtJ'1 re -W, t"Hum LATE ISSUEL <br />�1 q crrrfaPt--i.ni d,r) 1 <br />✓IIU� / �P•ARCELSUE T ' D USE/ APPLICATION .Z <br />-, <br />Crr4STATFJZP_ 1T de -19., (-N % 5ZZ'Ae <br />s, Inc <br />Pm, 209-887-3554 <br />CMIST„f,.,Linden, CA 95236 <br />PHONE <br />CAYiSTATFMP <br />377923 EIPMATIaN DATE 7/3-2, /1 <br />©omEsnC1_iVELL SAmPuNr.: _ General MnerallCafiiform Bacteria (4391) C Dibn=chloroprapane (4392) 7 Arsenic (4393) <br />INInDM Ea IJSE I DOM.FA JP/ivale 9.lian/Agricultural U Industrial C WaterQuaEty Moaitonng Q Sail SampringfCharacte-i2a6on <br />C Pubfic V*def System <br />IfeWerectImm Avner. Walersyst_Nuc contau Maim or Pnm= Nurvbw <br />TYPEOPWORK ❑ NevrtNel C Replacement VMI 0 Wen PolerWiwVMadiFmGcn D Other <br />❑ Manilortrg Well(s)__ E at wells G SO] Bafing(s) ccrconays C Geolechnit al <br />G Out-Opsenrice Well D Out-OfSelVice Well Renewal 7 LYossCoratec7on Repair <br />D Nevr Pumo 1(Purw Reclacernern k Puma Repair MAVC_ A -I RaLs Vlfp l (`—d— <br />..�.....�Nz,nw,.vry <br />I)TVIngMethod D Mud Ratary C AirRatsry D Auger D C`ableTcol 0 PruhPoint ? Other <br />Proposed Weli Depth ft Excava Gan m diameter _ Open Bottom U Gravel PacidGravel Sae in diameler <br />❑ CanductorCasinp in diameter f CondudarCasing Depth ft <br />Well Casing Oiameter_ in Thilmess/Gauge/ASTIMSched = Slee€ ❑ P►asic C Stainless Sleel 3 OUter <br />Grout Seal Depth ft :) Pleat Cement (94 1bDaoro-70 galwate4 ❑ Sand Cement sackmirl7 gal wafer <br />0 Bentordle (20%so,ids) D Other <br />Grout Placement Method ❑ Pumped 0 Free Fall 3 Outer _ Retardant/Acceleratcr(neme) <br />i P_—AL Installed 9y 0 DrllW 7 Pump Caniractor ❑ Other <br />❑ Concrete Pedestal C4lmensfonsVlffdtn R Length RThrck in 't Clvistyeox 0 Stave Pipe <br />'P_ ghE SuDmersalel]Turoine ] Other HP_L__ Pumo S 11 Slanding Water Level <br />1 HEREBY CERTIFY THAT t HAVE PREPARED THIS APPLICATION AND THAT THE WORK INCL BE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. 1 ALSO CEt2'RFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE 1MT14 THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT t AM €N COMPLLMCE WrTH ALL <br />'.YO COMPEVSATIDN LAWS. <br />MWF�M2 VANCE NOT(CE REQINRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />StGN .GG�(2f�cG T,,Sorporate SecretarlyATE <br />AcceDled By00k. <br />PA TMiEZu <br />NLYApFliczlian <br />oat NT <br />Area Flrtployae 109 A" <br />Graut Inspeclian ey <br />Date <br />1 SPECIAL.Well Well Permit <br />Pump Inspection By r 1 tsv w(\i ((1�(C <br />" " <br />QP hM Date t tJ !1I <br />" <br />❑ WAfvER Received <br />Sail Baring Inspection By <br />�� <br />Dale <br />Constructed Well Depth <br />ft <br />COMMENTS <br />ENLe3-05 WIM <br />vtn_L rrurtn Pmrur <br />En <br />m <br />D <br />0 <br />m <br />m <br />Z'd tZSU 860Z 01.11 SJGII!JQ 801_1131A.ind e80:06 96 9 6 100 <br />