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r <br /> ^ �^� 5LiLA �� ��-16 IJ.'y"N5610 '°N WdSO ti 9106 '06 '100 ;UJ Ii pIA1 0 <br /> WELUPUfWP PERMIT <br /> SAN JOAQUIN COUNTY EM1VIRONMENTALHEALT14 DEPARTMENT 1868EASTHAZELTONAVENUE-S-raMTDNCA95205-{209)468.3420 <br /> NON-REFUNDA$LE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> IJOaADDRESS 12255 E Eight titIle RD caymPStockton 95212 <br /> cROSssTRaEr JackTonL- RD <br /> APN !�_PgRCEt SIS NO US'e APPLTCATICNR a <br /> AWNERNAME Richard ZolezziX209-482-0347 <br /> PHOR <br /> DINNER ADDRESS P.O. Box 772 CIMSTAIML i n d e n CA 95236 <br /> 1CON11 ACTOR Purviance Drillers, Inc_ PHOW 209-887-355 <br /> �CoxrucToRADDRESS P• 0• Box 64 CtTr1STATr Iai.nden, CA 9523 <br /> FEES LelCONTRACTOR <br /> PHON;E <br /> SUSCOUTRACTOR ADDRESS C[TYISTATEIZIP <br /> LICENSE L:G•57 C-61 1 D-09 _OlherNUtta� 3 7 7 9 2 3 EXPIRATION DATE 7/31 J 17 <br /> G eOGRAFMCAL INFORMATION: Coordinates X Y Township_ RSnge Section_ <br /> INTENDEDUSE _DemestlCIPAvale a NlrrigaboNAgriculturat L:Industrial --Water Quality Monitoring -Sal Sampling,Charad3erizayon <br /> I PublIC Water System <br /> ITdirm-I ham Owner. aver )5 m —` dart ame w. na unman <br /> YPE CF WORK _New Well _Replacemenr Well ' Well Nierationi M!odilication _Other <br /> INaNtoring Wells) sof vleils j"Soli Bering(s) awbcrinDs r Geolechrt:cal Got borings <br /> Out-Of�erviceWell -gut-Of-Service WellRenexal -I CrossConnection Reoeir <br /> WELL�New PUMP Z:Pump Replacement 9 Pump Repair r-QCjA., =Raise Well Casing <br /> Met6tod <br /> lud Rotary _Air Rotary ..Auger _Cable Tool _Push paint Other <br /> PropeeDepth_ft Exca'laHon in diameter L Open Bollorrt 7 Gravel Pa:AGravel Size in diameter <br /> CDnduclor Casing in diameter f Conductor Casing Depth ft <br /> Well Casing Demeter_in Thict:IesVGauge/ASTMSrhed Steel Plastic _SlainessSte"1 2 Other <br /> Grout Seal Depth R Neat Cement(94/b bag1&jo9af vrataQ Sand Cement <br /> sack 111 l gal water <br /> 3entrnite(2D°SsolidsJ ::Other <br /> Grout Placement Nlethod :Pumped -;Free Fag =Other _.Retaniant 1 Accelerator(Warne) <br /> PEDESTAi Installed By - Oder �Pump Contractor Other <br /> Concrete Pedestal:Dimenbiorts:Width II Length R This* in :_Christy Baud e <br /> LEAM? Submersible 1Turbine Other HP PLvnc Set ft � laidingVValerLevel� 8 <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, STA i E LAWS,AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND A <br /> THAT 1 AM IN COMPLIANCE WITIi ALL <br /> WORKERS CCIAPENSATION LAWS. <br /> MUM ADVANC)c NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7897 <br /> sIGIa= _. - T, Corporate Secr,-t-Ebr <br /> I <br /> 1 <br /> I <br /> f i l l �' <br /> i t I C f VE <br /> I I <br /> ! I CT 2 0 2016 <br /> f <br /> ' I A'M' IAL HE,4L7-H <br /> l MiT/CERIvjCES <br /> iI <br /> f I i <br /> I i <br /> II 1 i <br /> E <br /> PTMENT 4SE PNLY <br /> Application Accepted Dal-1101701Are. GjA Employee lD; �Jv <br /> Grout Inspection By Dale 7 SPECIAL Well Permit H <br /> Pump rnspection Ey L-lave Dale D WAIVER Recelved Q Z J W <br /> SDU Bonin TnspoGfon 8Y Dale Constructed Welf Depth i w t� 4 <br /> COMMENTS C"Ie°�z c <br /> W > 'r _ <br /> Date zWa <br /> W <br /> l PE SC Received �r7� Amount Perm S Cq 5 C w <br /> Codes Info 8 VC Aemil2d:d Service RegL¢SL 7C Invo7ce# 'NeF11D7f ''.. U 0 <br /> i ��'`�� Id-�y-� 5�o�76c43 WPQoag33 aaCC <br /> W <br /> 12 WELL IPUKIP PER.'IT <br /> C d VL90L9960Z oul siellua eoueiAand d0 L:L l ZO OZ AeW <br />