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9690 -ON N00:6 I10Z 'LI 'upr acrid paAI ;D <br /> VVELL1PUMP PERMIT / <br /> SAN JOAQUII COUNTY ENVIROMIFNTALHEFL-nt DEPARTMENT AE66EASTHAZ3ION AVENUE-STOMTON CA SS205-(209)466-3420 r ✓ <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DAT ISSUED <br /> JOSADORESS 7474 N Cox Rd CiTrfzt�.inden CA 95236 <br /> CROs SIRE /�o m s t o c k R D _ <br /> ETA APN � PARCELS2��a t,L�yayN.�On�nUS AuPLIICCAT104N <br /> CVJNER NA61E JT.9ti'7r•"C-rrC [+a�rav�r-a-v d�♦ V"Pyj 90T-- 1-2568 <br /> O WAER ADDRESS cnY/sTA7F1zIPL i n d e n CA 95236 <br /> CoNTltac-oR <br /> Pury0Inc . PHONE iance Drillers nc209-887-3554 <br /> � <br /> CONTRACTOR ADDRESS 2. 0- F3ox 64 CnY/SrA7PJZ P_ Linden, CA 9 5 2 3 <br /> ISU3CDWRAC7OR PHONE <br /> SLracoNTR°CTOR ADDRT'Ss CrTYISTATEMP <br /> ILIC-MISE L.C-3-7 -G-61 :.t0-09 -Other (�reER 377 92 3 EXPIRAMONDATE 7/31 /17 <br /> 1 <br /> GEOGRAPHICAL INFORMArM Coordinates X Y Township R2age_ Section <br /> .I:ar„rtoEDUSE =DomesticrPtivate . mgeton/Agtieultutal Industrial -V"arQuaIRyV.o iIodng -Sol Sampling/Characterization <br /> S Public Water System <br /> ttd��nr baro O•xner. rrr 3 ttn `� mnn am°°r a urm°r <br /> i <br /> TYPE OF;WORK _New,Nell ReplacementYVel We»AReralianfMadifealign -i Other <br /> Monttorin o Tof vmils _SoR Boring(s) °I yC' s Geotechnical :dmmegs <br /> Out-OrServlce V1eII -:Out-OF-Service Vdeu-Renewal +Cross-Connection Repair <br /> ?New PumD =Pump Re !acemenl i;.MD Repair_ C_yrg-N.L> Aaise Wee CDsin <br /> IWEL.L C045TRUCTION <br /> IDrilting Method _fJUdRotary _ Air Rotary ..Auger _Cable Tool _Push _ Other <br /> IIIIProposed Wall Depth fl Excavation in diameter _Open Bottom _Gravel Pari IG avel Size indiameter <br /> I :Conductor Casing in diameter / Canduclor Casing DeDlh ft <br /> Well Casing D-iameler in nidwes5/Gat D&&ASTNI Srhed ..Steel =Plastic --Stainless Steel :!Other <br /> 1 GrOULSeal Depth P. =Neat Cement(94JbbagCS-10Sa/tvatei) _Sand Cement sark rnbu7 gal rraler <br /> Bentonile(20%solids) Other <br /> (Grout Placement Method Pumped 7 Free Fail =Other +_Retardant I Accelerator(nante) <br /> EPL--m— rnstalled By =Driller -Pump Contractor _ Other <br /> Concrete Pedestal-.Dimensions.Y+fidlh R Length ftThlck in Christy Box Stove Pipe <br /> Ptnla SuhmemblelllTur .ne ..Other HP Pump Sel 0 It Standing Waler Level ft <br /> 1 T <br /> HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DOME IN ACCORDANCE WMI SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS,AND RULES AND REGULA-BONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS p'4Yj� <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE L10Eidsc HOARD AND THAT t AM IN COMPLIANCE WITH ALL Re.c FNT <br /> tNORKER SATION LA 'il - <br /> IINiM i 2 HOU E NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL{209)953-7597 ,� � <br /> S:GALo Tr,,. Corporate Secretes �I-15-rk '�� 18 <br /> /OA 2/7 <br /> 1111 I f , i I 11i I f °� <br /> l i I I I ► E'`�a�Rcc, M,- <br /> I i I I <br /> I III <br /> PI EIVE <br /> � <br /> ` I i I <br /> ! I I 1 <br /> I I I I i i I P 1 7 2017 <br /> ` I 111 i 1 <br /> II I <br /> ru. .ni <br /> Ll <br /> •' Il I i I <br /> I I P I I I I I <br /> { I 1 , <br /> t PAR`TMENTUSE4ONLY <br /> Application Accepted By Date t flirt( Areae{_ Employee IDk! <br /> Grout Inspection By Date D SPECIAL Wel(Permit <br /> Pump rnspeclion By Date 7 WAIVER Received <br /> Soil Boring inspection By Date Constructed Well Depth n <br /> COMr&'Nri s <br /> PE SG Received Check".! I Amount Date Perm'lU Invoice# WastD0 <br /> Codes Snfo _ Cash Remitted Service Request# <br /> V7 L <br /> I I I I <br /> rkD 12 tPUldP.'EIt.•r; <br /> tz <br /> V'd t'L9CL9960Z oul saellla4 eouelAand d00 90 ZO L L bny <br />