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w iuv% ,•II- I(, ,fir,.. BSWON AVH : H 9tH 'S •Sny ;foil paA1 0 <br /> WELL/PUMP PERMIT <br /> SAN.1OAOWN COUNTY EWf1ONMBNTAL HEALTH DEPARVAr TT 1868 EAST HAZER-TON AVENUE-STOCKTON CA 9520 S-(20!2)460-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> y <br /> ,los ADDRESS 21409 E Flood Rd Cr-rz1P L! n d e n C'A C)5r6— � <br /> a o <br /> LROy Smyser N Fine Rd APN ��Via►L PARc2t S¢E-7--- LAND USE APPLICATION x m <br /> OWNERNAmE G . B . Ranches PHDNc09-662-1421 <br /> OrMER ADDRESS P .0. 8 o x 673 CnY)STA—'bP (.; n d P n CA C;?16 <br /> G„-'NTRACTOR Purviance Drillers, Inc. PHONE 299-887-3554 <br /> CONT C'=ADDRESS P. 0. T3 o X 64 CRYJSTATEMP Linden, C A 9523 <br /> SUBCOWRACrDK PHONE <br /> SUBCONTRACTOR ADDRESS CUPSYAT-�tl <br /> LrceNSE a CS7 L C-61 ,D609 _Other NUMBER 377923 E,,,...DATE 7/31 /17 <br /> GEOORAPHICALINFORM 71012. Coofdinates X Y Township, Range Section <br /> IUM40EG USE _DornesGrlPrivate ■ImgaIion/AgriWhA-al G Industria! Water Quality Monitoring D Soit SamplitlglChx=er®lran <br /> IJ PUDlic Water System <br /> rtmiro thom Ow r. Cor ere umaer <br /> TYPE OF WoRx _,NewWeg _Replammeni V1lell _Well AHer2tioM4ladifeaGon ::Other <br /> =arbar"s Velborrgs l <br /> :-A,loridoring Weli(s) #ofwells ��Soi{Borings) �GeOlet3oti�3 <br /> :.7 Out-af-servtce Well 7Our-OfServite Well Renewal i.Cross-Conneclian Repair <br /> NewPtan p . lump Replacement _Pomo Repair t i Raise Well Casing { <br /> '/ELI.,CC14STRUCTlDi7 <br /> Drilling Method -Vad Rotary -Air Rosary -�ALger _Cable Tool .Push Print _t Other <br /> Proposed Well Depth h FscavaUon .in diameter _ Open Bottam C Gravel Pac)rlGravel Stte in diameter <br /> ConduclorCasing in diameter r ConductorCesing Depth R <br /> We11 Casing Diameter!in Tbictness/GaugelASTM Sched = Steel Plastic L Stainless Slee) C Other <br /> GroutSeal Depth ft =Nea:Cement(941nbag/5.70gafvmie4 7 Sana Cement sack frde7gal water <br /> :'I Senlonile(26%solds) -,Other <br /> Grout Placement Method M Pimped ,_Free Fall !:Other C Retardant I Accelerator(name) <br /> PEDESTAL installed By 0 Driller -Pump Contractor C Other <br /> u Concrete Pedestal'-Dimensions:Width R Length R Thick In Christy Box U Stove Pipe <br /> Puuly -SubmerslbleiTurbirie ._I Other HP= P.,S fi Standing Water leve R 5 -I <br /> I ID <br /> HERESY CITIFY THAT I HAVE PREPARETHIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY CRDINANGES, STATE MWS, AND RULES AND REGULATIONS. I 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 /> WORKERS COMPENSATION LAWS- <br /> UM ADVANEE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7597 <br /> SI Tti Corporate Secretal (� !P I <br /> I 1 l I <br /> ly <br /> i I E <br /> I 1 _ <br /> 2016 <br /> I 53' i ` 'AEPJTAL HEALTH <br /> 1I ERMITiSERWCES <br /> o I <br /> PAYMENT 1 <br /> RECENED <br /> EPARTMENT USE NLY e , <br /> AUG10 20% Applfcatim Accepted By Date Area�T EmployeelDB�(b/tj(V <br /> SpN JOAQUIN COUNTY Grout inspeLton ey— Dare -D SPECIAL Well Permit <br /> ENVIRONMENTAL pump Inspection ey Date 7 WAIVER Received <br /> HEALTH DEPARTMENT <br /> Scll Boring frlcpealan By Dale Constructed Well Depth H <br /> COM&IENTS <br /> PE SC Received Cheekdl Amount Permit/ <br /> Codes Into BY Cash Remirtnd Date Service <br /> RevueStL' invoice# Well IDA <br /> Eh•D B3�lB �T �!�..1.t.PU7D PE�rAfi <br /> Ira(1117. �/ <br /> S'd tZSCZ2960Z oul sjell!j4 eouelnind d6Z:90 Z090J2N <br />