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9860 "N Adti8: 9 9101, -8l 'lnp awil paisWa�ad <br /> ' WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY EYVTRCNMEWAL HEALTH DEPARTMENT 1868 EAST HAzLLTOM AveNur-STOCKTON CA 95205-(209)4884420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> I H <br /> JOB ADDRESS 10619 N ST RT R 4 Hwy c,Tymp Stockton CA 95212 <br /> 0 <br /> CROSS STREET E i W h t NI I l e RD APIN_06>l u 21 PARCEL.S -9-tL LAND USE APPLICATION# A <br /> OWNER NAME Brian Colburn PHOw?-09-887-3554 <br /> Z�t-493-CXJt',S <br /> OWNER ADDRESS _P 0 Box 754 crrY/sTATErzPC 1 e m e n t s CA 95227 <br /> CONTRACTOR Purviance Drillers, Inc. PHONE 209-887-3554 <br /> CONTRACTOR ADDRESS P. O. Box 64 CrY/STA7Er7rP Linden, CA 9523 <br /> SUBCONTRACTOR PHONE <br /> SuecoNTRAcTcR ADDRESS CRYISTATEf7jp <br /> LICENSE LJ GSt U C-31 J D-09 U Oter NUMBER 377923 ExPIRAT,DN DATE 7/31 /17 <br /> GEOGRAPHICAL INFORMATON: Coordinates X Y Township_ Range Section_ <br /> INTENCED USE is DomesSdPrivate ;1 lrrigatiorvAgricullural G Industrial L Water Quality Montloring 0 Soil Samptirtg/Chalacterizalion <br /> U Public Water System <br /> 11dir-1,11vm Own a: war., em me n anew one umoer <br /> TYPE OF WoRx Lr New Well Replacement Well u Well AlteraboNModfication :1 Other <br /> i!Monitoring Well(s) #of wells n Soil BOring(s) 0"t' 95 r Geofechnicat I ceboA"a' <br /> n Out-Of-Service Well r Out-CfSetvice Well Renewat n Cross-Connection Repair <br /> •New P _ Pump Replacement C Pump Repair 17 Raise Well Gazing <br /> WELL CONSTRUCTION <br /> Drilling Method _Mud Rotary i_Air Rotary i Ruga L Cable Tool 11 Push Poirl a other <br /> Proposed Weil Cepth ft Excavation in diameter ❑Open Bottom G Gravel Pack'Gravel Size in diameter <br /> CoHduclor Casing in diameter 1 Conductor Casing Depth ft <br /> Well Casing Diameter_in 7hidoess/GaugeiAS7Nt Sched 0 Steel G Plastic C Stainless Steel C Doter <br /> Grout Seal Depth_fl 0 Neat Cement(94 ib bag'-'L-10 gal water) C Sand Cement sack r bob gal water <br /> Benlcnite(26116soLds) n Other <br /> Grout Placement Method C Pumped �: Free Fall G Other C Retardant I Accelerator(name) <br /> PEDESTAL Instalfed By C Driller i)Pump Contractor G other <br /> U Contrera Pedestal Dimensions:Width R Length it ThicY in ri Christy Box a St:DYe Pipe <br /> PUMP •Submersibles,Turbine a Other HP Pump Sal ft Standing Water Level R <br /> I HEREBY CERTIFY THAT 1 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. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT t AM IN COMPLIANCE WITH ALL <br /> W <br /> PENSATION <br /> MINI M ANCE NOTICE REQUIRED FOR INSPEC7?DNS-PLEASE CALL(209)953-7897 <br /> SIGNED /GG cc TITL,, Corporate SecretagTy �b /(,n, <br /> t <br /> i I <br /> i I �Lj <br /> i I r <br /> 016 <br /> L " HEALTH <br /> PrnlplZ AGES <br /> r <br /> i <br /> DEPARTMENT USE <br /> E ONLY PAYMENT <br /> Application Accepted By Date \Z b Area _ Employee 109 ECE'V <br /> Grout Inspection By Date ❑ SPECIAL Well Permit ED <br /> Pump Inspection By (YK Date CI WAIVER Received JUL 2 O 2016 <br /> COMMENTS Baring Inspection By - n Da!r.r ` - stat d�� th '` E��agU►N CAU <br /> PE V SC Received' Chec Amount PertniL �' EIEdLTN U Pq TIUFNn <br /> Codes Info B Cash Remftted Date Service oast# Invoice# WellIDO T <br /> J V7� tA V1SGt i <br /> E1-0 42.05 wELL IPUMP PERMtr <br /> sgmv -- <br /> t�'d bL9£L8860Z oUi SJaiiiJQ e0Ue1Aand eZlv:L0 ZO 9 L qej <br />