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OSH "N 061jOl LIN 'S6 *d1S awii paAia��a� <br /> t WELUPUMP PERMIT �✓ <br /> t , <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 FAST HAZELTON AVENUE-STOCKTON CA 952CS-(209)4683420 <br /> NON-REFUNDABLE PERIIrT CALL 209 953-7697 FOR INSPECTIONS EXPIRES'I YEAR FROM DATE ISSUED <br /> LAI <br /> JOSADDRESS 8707 E Harney Ln crrv/ZFLodi CA 95240 <br /> D <br /> CROSS STREET Alpine Rd ApN 04-30 7053 PARCEL StgILAND USE APPt1CAncn# m <br /> OWNER NAME Elizabeth TGi18� CAb, n F.,D409-327-8240 <br /> OWNER ADDRESS 8707 E Harney Ln ,/��� &X Y$3 GlrwsrATFJ2IP L o d i CA 9 5 2 40 <br /> CONTRACTOR Purviance Drillers , Inc . "09-887-3554 <br /> CON TRAC TOR ADOTtESs P -O.Box 64 Qr„y-rA, Linden, CA ')5236 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATFIZIP <br /> LIc3Jse K;G57 U G61 u D-09 a Other NUMBER 3 7 7 9 2 3 EmRAnoNiDATE 7/31 /19 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township! Range Section_ <br /> INTgNmo,Use jillspornesticJPrivale, U In(gation/Agricutural f!Industrial C WaterQuatityMonitering ti Sal SamplinglCharaclerization <br /> Li Public Water System <br /> It dlRerem trim Owner: aver System Name on am ar .ane um r <br /> TYPE OF WORIt U New vVeR L Replacement Wet U Well AllerationVodiScabOn Li Other <br /> n Monitoring Wel l(s) 0of'ae1s; r Soil Boling(s) Rol bodngs I-Geotechnical Wdbu q, <br /> n Out-Of-Service Well I'I Out-Of-Service Well Renewal n Cross-Connection Repak <br /> J New Pum )kutinp Replacement U Pump Repair n Raise Well Casing <br /> WELLCONSTRUCTION <br /> Drilling Method U Mud Rotary ;- Air Rotary I Auger :I Cable Tod I Push Point I Other <br /> Proposed Well Depth ft Excavation In diameter C Open Bottom 7 Gravel Paclt/Gravel Size in diameter <br /> Conductor Casing n diameter / Conductor Casing Depth It <br /> Well Casing Diameter_in ThicknessfGaugetASTM Sched -Steel O Plastic L Stainless Steel C Other <br /> Grout Seal Depth R C Neat Cement(94 Ib bag'540 gat water) J Sand Cement sack rrdxl7 gal wale <br /> 7.Bentonite 420%solids] r'Other <br /> Grout Placement Method L Pumped C Free Fall =Other in Reiardam/Accetemtor(name) <br /> PEDESTAL Installed By !!Driller C Pump Contractor CJ Other <br /> I Concrete Pedestal L Dimensions:Width ft Length ft Thick in - Christy Box LI Stove Pipe <br /> al,—M, ubmersdlleu Turbine U Other HP Pump S Il Standing Water Level t <br /> t HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE PATH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> W OMPENSATiON S. <br /> MIN UM VANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGN TrruCorp Secretary DATE ?-4=/7 <br /> I <br /> 'I C <br /> 1 <br /> S� FcF �r <br /> p? <br /> I i o04 C U <br /> EPARTMENT SE ONLY / <br /> Application Acoepled By Date '%25-0- Area y lg Employee ll[W c/ <br /> Grout Inspection By Date !n f 0 SPECIAL WeII Permit <br /> Pump / <br /> Prp Inspection By Y Date � WAivER Received <br /> Soil Boding Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Cheek#1 Amount i Date Portniu Invoice# Well ID# <br /> Codes Into Cash Remitted ; Service Re uest# <br /> O,D43,Je6 Q WELL/PtR.W°_RMR <br /> 4rjDn2 -4 <br /> £'d tiL9£L9960Z out saelliJd eoueinund 881:01 L 19Z deS <br />