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L091 "N WdSl :Z L I 0 6 1E 'APA ;UJIl paAIa).J,� <br /> WELLIPUMP PERMIT � <br /> ` SAN JOAOUIN COUNTY ENVIROMTENTAL HEAL-rH DEPARTMENT 1869 EAST HAZFLTON AVENUE-SmCKMN CA 95205-(209)4683420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR IN5PECTIONS EXPIRES 1 YEAR FRCAI DATE ISSUED <br /> JOB ADDRESS 832N Fine Rd CITMr1jPLinden CA 95236 m <br /> D <br /> CROSSSTREET F i r s t Ave APN �• PARCELSLZE LAND WE APPUCATIDN# m <br /> OWNER NAME Patricia Solari ��_ � rye( PHONE209-887-3124 w <br /> DINNER ADDRESS 8 3 2 N Fine R d' ���� ?� � -TTEr—-Linden CA 5 <br /> CONTRACTOR Purviance Drillers, Inc. PHONE 209-887-3554 <br /> CONTRACTOR ADDRESS P. 0- Rox 64 Cm/STATErzIP Linden, CA 9 5 2 3 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATEJZP <br /> LICENSE L C-57 C-61 D-09 Other NUMBER 377923 EXPIRAnON DATE 7/31 /17 <br /> GEOGRAPHICAIIe/FORNATIOm- Coordinates X Y TOwnehfp_ Range Section_ <br /> INTENDED USE NDomeslicdPrivate -lnigalion/Agricultural Industrial WalerQuality Monitoring C Sol SampSng/(Cheracteri ation <br /> PubllcWaterSyslem <br /> IFdifrereot lrom Ovmer. er em e n or ra v <br /> TYPE OF WORK. _New Well ;- Rcplacemenl Well ::Well AVleralion9hlodi6ralion -j Other _ <br /> MonA0ringWe1I(s) ttofvMls SoilBoringfs) eotnonngs - GeOtechnip! Aorborirgs <br /> Owl-Of-Service Well _Out-OF-Service Well Renewal _Cross-Conneclion Repair <br /> Ne%vPump Z Pump Replacement it Pump Re air =Raise'Well Casin <br /> WELL CONSTRUCTION <br /> Drilling Method '-i Mud Rotary _Air Rotary ..Auger _ Cable Tool Push Point _ Other <br /> i <br /> Proposed Well Depth ft Excavation in diameter =Open Bullam =Gravel PaWGrauel Size in c5amoter <br /> L Conductor Casing in diameter / Condlrctcr Casing Depth ft <br /> Well Casing Diameter in Thidmess/GaugefASTM Schad :Steel Plastic -Stainless Steel Z!DRter <br /> Grout Seal Depth_n c Neat Cement(94/b beySfOgal nater) _Sand Cement sack rrAmn gal wailer <br /> -Bentonite(2D'.b solids) 'Other <br /> Grout Placement Method .-Pumped Free Fall -Other G Retardant i Accelerator(name) <br /> PEDES?AL Installed By =Driller Pump Contractor Other <br /> Concrete Pedestal_Oimensions:Width It Length It Thick in L'Chrtsry8Ox -_j Stove Pipe <br /> awIm, .ASubmersrbleL:Turbine Other HP Pump Sat R Standing Weler Level fI <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN PAYMENT <br /> IOAQUCURREINTCOUNTY AND ACTIVEfNANCES, STATE S.AND RULES AND UTH THE CALIFORNIA CONTRACTORS STATTEEDLATIONS. I ALSO CERTIFY LICENSE BOARD AND THAT 1 AM IN COMPLIAT MY ANCE aTiq ALL LICENSE lJS RED IVED <br /> WORKERS COMPENSATION LAWS. JU <br /> IAHM=24OqVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL{209)953-7697 N O 2 2017 <br /> ili?�t« T,. Corporate Secretes 531-�-7 sa», ,oAQUp,ro <br /> HFALTHDE NMEI�IT,ti <br /> I i PARIIFENT <br /> I - T <br /> I <br /> i <br /> I <br /> AV <br /> ilvoo�. <br /> II I I T a <br /> PA TMENT V E NL <br /> ApY <br /> pllcallon Accepted BY ate Area Finptoyee IC* ( �{� <br /> Grout Inspection By Date D SPECIAL Well Permit <br /> Pump inspection W Date .3 WAIVER Received <br /> SDII Bening Inisp�ection By Date Consbucted Well Depth ft <br /> COa�Iw14TS InA� <br /> PE SC Received I Checkw Amount DatePenniU lnvolca# well IDU <br /> Codes Info BY Cash Remitted Service Request 4 <br /> �o1 ��ol� ,Ev_mur:�PraT,I- <br /> 4/3tit, <br /> Z'd VZSCZ9960Z oul saalli.lQ eoua/und d0Z:Z0 L L lE AEW <br />