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LL`) •°N WH81 :6 8 [OZ '8 'unr ;alit paA ! ;3; 'I1 <br /> VVELL.IPUMP PERMIT <br /> S0.4JOA7VNC6UNiYEYYRONMETITALHEALTNDEPARMENT 1150 EsTii--,4AVE1W-STGCK7UMCA95285-(209115&-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Jol1AowMss 29598 E Shelton Rd Cr,.rMV Linden 95236 m <br /> C.—SlT-- l� q, V �i L�<rJ ( N ' C) PasrGEi.S o-E.A141lc-- v <br /> ovut•,,,tvA oris Culver/Fred Jimenez PHONE <br /> OWNER ADDRngs-2 9 59'LC S h e l r_o n R d/31z3C� / cnvisTATEo, <br /> CoN7PA oR Purviance Drillers , Inc PHONE 2 .19-887-3554 <br /> CONTFACTUR AuoRFSS PO Bog 64 crrYlsra,�0PL i n d e n, C A 95236 <br /> I <br /> SuscaNtRACTOR PHONE <br /> SuscowrRAcma A110 E9s Cr OSrATE1Zrn <br /> LICEMr; X.C57 D C-SS ❑069 U Other NUtdaHt El%MAnDRUAAT6 <br /> DorsPSTcclh7aiL S atrLtnnza:0 General MineraXnliform Bacteria(4391)F Dibrnmochloropropane(4392)--Arsenic(4393) <br /> INTENa€DUse IS DornedWPiivate C IrrigaliuNAgricaltural `Industrial C WaterQua1ity M0m?oring O Sob San:plingrCherr;cteriz9tion <br /> O Publ:c water Spstrm 4.:4 <br /> i ,fd,Geetfiam Cnarr. Ylirer STstm Nrrre GarunG Amus or Ptrme NonDer <br /> TYPE OF WORK L:Neil Well C Repl20ement`ivall C YVellAIleratimmodirication S Other <br /> o Monitoring WeN(s) 4 Cf Weis 0 Sag saTing(s) =01 bis r Geotechnical 0.10. /! <br /> ❑Out-afSenrire VVell C Oul,-OlServic=Well Renevral 0 Crass-ConnerEen Repay <br /> R <br /> NevrPamPmRelacmenPRepair O RiseWll Cn <br /> WELLCoMMucnoN q 018 <br /> DrIVIn9 method O Mud Ratary C Ar Rotary C Auger O Cable Taol O Push Point 1) Other / N C <br /> Proposed well Depth ft Emvation in diameter C Open Haltom G Gravel Pack/Gravel Sae In Lraiii, MFN UNTy <br /> ❑ConG <br /> duorCasing in diameter r Conductor Casing Depth It '9RTM t <br /> Weit Casing Diameter_to Thickne-alGaugeIASRA SCh --,Steel O Ptas[c n Slsintess Steel D 011ier FHT <br /> Grout Seal Depth R ❑Neat Cement(94/b har�aTOga7warer} O Sand Cement sack rnb/7 gal Crater <br /> o t3enturHte(21796 Bonds) ❑otr,er <br /> Graut Placement Mabod C Fkrnped O Free Fall D Other Retardant lAccelemter(oame) <br /> P®t:9T— totalled Hy O Driller D Ptunp Cal actor C Other <br /> ❑Concrete Pedestal ODlmensions:Y'lidth It t gth R Thick in n Chrtsry Boz D S e Plpe <br /> P nuP I SubmerslbleD Turbine C Other HP Pump szec Standing Water Level ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL aE CONE IN ACCORDANCE:WITH SAN <br /> 1OAQUIN COUNTY ORDIMANCES, STATE LAWS, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WrTH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AIN IN cwPLANCE wrm ALL <br /> WORKERS COMPENSATION LAWS. <br /> Itdl 24 U VANCE NOTICE REQUIRED r/F�OR INSPECTIONS-PLEASE CALL(209)953-7637 <br /> S1G+Eo /{� T,n OrpDrate Secretar&A-m - tel <br /> I I <br /> Aral ! <br /> Q2 Lu�LL i <br /> mama= <br /> N Z I t ! <br /> oa LitI <br /> Uj G W r!) I <br /> -) C) tl <br /> a <br /> > f <br /> z <br /> u <br /> i I <br /> 11 I <br /> I r I I <br /> A M E NT U E ,nyr'�T�-Y <br /> Application Accepted By44 ale �V Areae Employee IGY� <br /> GM L Inspection By Data L7 SPEC1ALWell Permit <br /> Pump InspectlCn ByINA/,)71 Data f�" . 7 �'' ( CI WAIVER Received <br /> Sall Bcntng J nspecfinn By O a e Constta cta d Well Oepth R <br /> COMMENTS <br /> PE SC Received Checit#f/ Amatmt Qat Petm t/ Involve# Well lD# <br /> Cortes Info h Remitfid Service Rea uest# <br /> O1 ( -) <br /> I - <br /> Z d t'Z9U2960Z out S-lelll-IQ aouelAind e69:90 2 L 00 Unr <br />