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1991 "N AV11 : 11 t1H Z1 'unr awil p;Ai ;oq <br /> WELLIPUMP PERMIT � , <br /> SAN JOAQLIN COUNTYENVIRONNENTAL HIcALTR DEPARTMENT 1869 EAST HAZFITON AVENue-STOCKTON CA 95205-(209;4883420 <br /> NON-Rr=FUNDABLE PERMIT CALL( 91953-7697 FOR INSPECTIONS EXPIRES 9 YEAR FROM DATE ISSUED <br /> Joe ADDRESS 2�?�Ol G /caniii crrid e n Ca 95236 <br /> m <br /> b <br /> c'7CROSS STREET- ��A.I(.., l APN Q�3 0&700 b PABCELSIZE LIarn:USE APPLICATION x O <br /> NAME C A' Paa09-639-4402 <br /> 1" <br /> IOr9NER ADDICESS. /is u �1►�, CMISTATEM Ca - 3 C) 2 3(o <br /> CONTRAC[OR Purviance Drillers, Inco PHONE 2 9-587-3554 <br /> CONTRACTOR ADDRESS p- C- '3 o x 64 CRyI STATElZtP Linden, C A 9523 <br /> SUBCOYIRACTOR <br /> PHONE <br /> SUBCONTRACTOR ADDRESS CrlYJSTA-,VZP _ <br /> LICENse _G57 _C-61 D-ag _Other NUMBER 3 7 7 9 2 3 ExPtRAnoN DATE 7/31 /17 <br /> GEOORAPRICALINPORMATION: Coordinates X Y TownShip� Range Section <br /> INTENDED UsE =DorrlestiUPrivate j UngatioNAgiculturel Industrial Wf Waterouaity Monitoring' t_Sail SamplinglChamctesization <br /> Public WalerSyslem <br /> adiRerem kem Oumcr_ rerars em ame an a ame w rte umxr <br /> TYPE OP WORIS New Well _Replace,"nent Vi _,Well Allerationi'Moditiration .J Other <br /> Monitoring Wells) a of v,ells I i So18OIing(s) :m bodnas � Geolechi t 01 baratgs <br /> Due-Of-Service WellOut-0ISenice 4Ve11 Rene,val Goss-Connection Repair-- <br /> �.New Pum Z Pum R lacenrent 0 PUmp Repair =Raise'JVe11 Casing <br /> WELL CONSTRUCTION <br /> Driliing Method Mud Rotary _ArRolary ..Auger Cable Tool :Push paint Other <br /> Proposed Well Depth n Excavadon In diameter _Open gotlom Gravel PaciJGravel Size n diameter <br /> Conducla-Casing in diameter I ConducterCasingpeplh H <br /> Well Casing Diameter_in Thic knesrJGaug&ASTIJI Srlred $eel Plastic Stainless Steel 7 Other <br /> Grout Seal Dep6ti h C Neat Cement(941bbagi gal�nai _Sand Cement sao4 tnL"7 gal%rater <br /> Benlonlle(20%sofids) ;1 Other <br /> Grout Placement Method G Pumped ri Free Fall =Other C Retardant/Acceleralor(nalne) <br /> PEDESTAL Installed By D Ddiler ^Purm ContraeSor - Other <br /> COrrcretePedestal:_Dimensions:Wfdlh R Length rt Thick in a Christy$ox �j SlcvePipe <br /> SubmersibleL.Turbine Other HP Pump Set k Standing Water Levei R <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL. BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUI4TY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> 'CURRENT AND ACTIVE IMTH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> N ENSATI S <br /> 1111 FA 2 VANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SrcWEO Tin..E Corporate. Secreta r !o-I z 1 7 <br /> I EF <br /> I <br /> ! EIVED <br /> 4-fill FI ! <br /> r 1 2017 <br /> ENTAL HEALTH <br /> /SERWCES <br /> �/ ! l R AY4f, <br /> eb <br /> wi <br /> N <br /> E4vA <br /> ; DUpy <br /> ARTMENT BEf� NLY `WCrh,806NOU�� <br /> Application Accepted By Dale i / Area (C <br /> Employee lJ (R7y4E� <br /> Grout Inspection By Dace V 11 D SPECIAL Well Perrnit <br /> Pump Inspection By Data 3 WAIVER Received <br /> Sail Boring Inspection By Dale Constructed WeR Depth h <br /> COMMENTS <br /> PE SC Received Chec)w Amount Date PerrnW <br /> Codes into B Cash stied ServiceR estK Inotc $ WeBIDrt <br /> 16 1 iso— .`� 13 5R a 716 3 <br /> ` I <br /> .f3v12 fTLL rPUGD PER Mfr <br /> £.d tiL9£L8860Z oul sielllJQ aouai/und aZZ:L L L L Z L ung <br />