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=� 1 Sc�..—►-�t�—I(� �h ^'� 9260 "N WdtiB 9 9 l 0 Z 8l 'lnI, awil p;A 1 ;0 <br /> • VVELUPUNIP PERMIT <br /> SAN JoAou1N County ENVIROmmENTAL HFALTHDEPARTyENr 1668 E"THAZEITON AVENtie-STOCKTCH CA95205-(209)466-s42D <br /> NOK-REFUNDABLE PERNST CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> y <br /> Jos AODRess 12123 E H t r D�7�96 t�+( C-op_L i p d e n—)5 23 6 > <br /> CROSS STREET N Thompson R U A P N LA'i v` 1 PARC.L S= 2(. L.USE APPUCATON$ S <br /> Ovrrt:R NA,&- Dave Archer PHONE 7 0 A—6;cam,li 01 <br /> OWNERADDRESS 15764 H w y 26 crnrlsTATErzv T.; in rl P� r e a S—n-� 6 <br /> CONTRACTOR Purviance millers, Inc. pHA 2()9-ts$7-3554 <br /> CONTRACTOR ADDRESS P_ O. 3O X 64 CITY)5rAT a, L 1 E2d e II r CA q52-3 <br /> SUBCONTRACTOR NONE <br /> S UB CCHTRACTOR AODR5ss CITVISTATrIZIP <br /> L muse Li C-57 U,C-61 D-cs _OlheT NUMM 3 7 7 9 2 3 ExPmAroN DAh 7 131 /17 <br /> GE013RAPfnCALINFORMAMON: Coordinates X Y Township_ Ranga Section_ <br /> Itj1VxFDUsE U DpmesdcPnva:a WIrrig3lion1Agr'Cunurai c.Industrial WaterOu4yUlonitcnng F7 Sal Sampting/Characleem6cn <br /> 11 Puhlic Water System <br /> Ifdldammon mQ�mer_ or em ame ur a Amen unmar <br /> TYPE OF WORK NEW Well _ Replacement Wei) L well Alteral onfUDdifica ion Other <br /> Monitoring Well(s) #of wells -I Sdd Boring(s) �o10on`p' Geotechnical aof ti0rwN' <br /> Out-0f-Service We" 7 Out-CfSenrice Well Renewal f Cross-Connection Repair <br /> New PLsnp IF Pump Re tecement o PLLrnp Repair I:Raise Well Casing <br /> WELL CONBTRtWnON <br /> Drillfag Method _Mud Rotary Air Rotary :Auger _CabieTool .:Push Poirft ..: Other _ <br /> Proposed Well Depth R EmavaGon In diameter _Open Bottom --Gravel PacldGravel Size_N diameter <br /> Condldor Casing in diameter i Cmductor Casing Depth ft <br /> Wall Casing Diameter_ire Thida:ess[Gauge/ASTM SChed O Steel 7 Plastic C Stainless Sleet C Giber <br /> Grout Seal Depth_R j Neat Cement(g41b bay;5LlO gal Vrdler) =Sand Cement sack rnrrll gat water <br /> r:Bentani:e(2a%seas) Other <br /> Grout Placement Method 0 Pumped C Free Fag C Cther Retardant I AccE>Mtor(name) <br /> PEaSsTAL Installed By C Onlier Pump Contractor C Olher <br /> IL Concreta Pedestal_Dimensions:Wath fl Length it Thick in :.Christy Box C Stove Pipe <br /> uN� a SLd=ersibFeATurbine i I Other HP Pump SO / ft Standing Water Level R <br /> I HEREBY CERTIFY THAT t 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, t ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL - <br /> WORS( ATIo <br /> YlI M 26CO�=�ADNICE NOTICE REQUIRED FOR IMPECTIONS-PLEASE CALL(209)953-7697 <br /> Corporate Secretin - -, vDy` <br /> j O <br /> I <br /> I <br /> E L 19 2016 <br /> NMENTAL HEALTH <br /> IT/SERVICES <br /> I <br /> I <br /> i <br /> i ) <br /> I <br /> I <br /> I <br /> 1 <br /> F <br /> 1 <br /> r <br /> DEPARTMENT USE ONLY <br /> Application Accepted By r � Date � 'L�' �� Area l'K h Employee 1G# <br /> Gmat lnspredonBy Date ❑ SPECIALWell Permit PAYMENT <br /> Pump Inspeam By Dale S D WAIVER Received <br /> — - RECEIVED Daie Constructed Well Depth G " y _ fCOMMENTS � <br /> JUL' 2 S 2016 <br /> PE SC Roceivad ChecwAmount Data Permit/ I Invoice# Well l J AQUIN <br /> Codes InFo 8 Cash =luted Service R uestf IROME COUNTY <br /> OEPgRTAL <br /> 7MENT <br /> b'f 9 <br /> EXD 434" W 3L iT11A?D BiRIT <br /> ,,,aGn2 <br /> 9'd bL98L8860Z out saa11uQ eoueinlnd eEb:�0 ZO 91, qe <br />