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5610 'ON WdSO :ti 9102 'OZ '�10 11111 PIA I ; <br /> WELUPUMP PERMIT <br /> SAN JOPQUM COUNTY EtMRnV6iFMT4L HEALDi DepARTPAENT 1868 EASTHAzELTOxAVENuE-STOCRToN CA 5SZDS-(2097,456-3420 <br /> NON-REFUNDABLE PERMIT CALL 269 953-7697 FOR INSPECnONS EXPIRES i Y>=AARFRam DATE issllED <br /> JoaADoczss 23390 E Flood RD crry. tpLinden 95236 <br /> CRos9 s-mEET H W V 26 _APN jQn PARCEL S2r=f/ LFnD USE APPUC-AmON A <br /> OWNER NAME S C O t t S C o m R a n y PRONE <br /> OiW:ER ADWESs 23390 E Flood R n C—ISTATElZJ -i n rl P n C A C 42 3 6 <br /> CONTRACTOR Purviance Drillers, Inc_ PtiDNE 2219-867-3554 <br /> CONTAACTOR ADORF55 P. O. TI O x 64 CM)STA'EMP Linden, CA 9523 <br /> 5118 CANTRAc rOR PHONE <br /> SUBCONTRAC TOR ADDRESS CtTVISTAMEIZW <br /> UcETJSe .-A G.57 L G-al .,D-09 other NuNalER 3 7 79 2 3 E ,.TION DATE 7131 /`17 <br /> GEOORAPRICAL OR.4A1?wr Coordinates X Y Towrshlp Range Sectian <br /> Itrt[NDEDUs itva:a lnig " n/Agrioulural s nal --VvaterOuafiyMonilOnng I Soil Sampling/Charaderza5cn <br /> Publ=Water System �T JJ!//!� //yy <br /> •acararrt C°arOrner. r} 5 i T:1fn e %rnTcFremeu one sneer I <br /> TYPEOFWD.Rr( L idovVvall Rep6acement Well We11Al'erationfModificatCn Other <br /> mcnitaing WelKs) 9 O wells n Sod BDnng(S) "ot OorfA9� Geotechnical P°r mrn s <br /> cutO(Servit e Wel F7 Out-OfSennce Well Rene,.zl r Cross-Conrredion Repair <br /> New Pump L P=p Repfacement a Pumo Re at t,Rase Well Casin I <br /> WELL.Con sTRu cnou — <br /> Oriiltng Method .ULM Rotary Air Rotary _Auger - Cable Tool _Push Point Olhe,r <br /> Proposed Well Depth fl En:.Tvatiovr in diameterOpen Bolton = Gravel Pack/Gravel Size in diameter <br /> COndudorCasing in diameter / Conductor Casing Depth fl <br /> WDA Casing Mameler_in ThidtrrasslGaugalASTM Shed =Steel _r Plastic L Stainless Sted 0 other <br /> Grout Seal Dapth A -1 Neat Cement 094 Ib ba3,5-10gal water) Sand Cemwt Sack rras17 gal water <br /> Benlonile(20%sofids) Other <br /> �GmuI Placement Mathod 'Pumped ._Free Fall f-Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By �-Driller =Pump Contactar Other <br /> L_ _Con crele,Pedestal_DimerWons_V'ldth tt t.ength R Tb1rk In !:Christy Box Steve Pipe <br /> PUMA -2 S1lbmerslbleVTurdne r:Other PPPump Set _ ti Standing Water Level R 1, <br /> I HEREBY CERTIFY 7RAT I 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. I ALSO CERTIFY THAT MY REQUIRED LICENSE 15 <br /> CURRENT AND AC-n VE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPUANCE WrTH ALL <br /> WORKS MPENSATION LAW <br /> MINIM 24 ANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 1209)953-7697 <br /> StcNED Ti7LE Corporate Secretes <br /> i r <br /> I <br /> - <br /> i <br /> Y <br /> u I " <br /> a / <br /> da30Oa I <: ; Z�l�s <br /> a d I <br /> t_ yt:4L7'H <br /> S <br /> DEPARTlAENTte4LIFE O LY <br /> ApplicationAccYpled DaAreaEmployeeI ..d z z <br /> Gras Inspection By. Date ❑ SPECIAL Well Permit to -J c <br /> O OQc <br /> Pump inspersion By� -4 Date i:J D WAIVER Re Ceived ,1�j ; <br />