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ZSZti 'IN MH ll 8 I '0l '140 ;UJ il p;Aiaaa� <br /> WELUPLIMP PERMIT <br /> SAN JOAOUIN COUNTY ErltrrRONMENTAL HEALTH D EPARTrAwr 1 aB9 EASTHAZEuroN AVENUE-STOCRTON CA 95205-(209)4603420 <br /> _ KION-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 7 YEAR FROM DATE ISSUED ' <br /> J.13 ADDRESS 12867 P crnraPLodi Ca 95940 m <br /> a <br /> CRO55 STREET APN O �� �/, PARCELSRE nUSEAPPLlCAT1oN# 9 <br /> m <br /> OWNER NAME PJC Fami1 4T PHON�SA—SFS—nG7n N <br /> OWNS ADDRESS 1 2 4 CrTWSTATOZ <br /> CONTRACTOR Purviance nrlllers , Inc PHONE 209-897-3554 <br /> CONTRACTORADORESS PC -Box 64 CI Yl9TATEOF!L i n d e n , CA 95236 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESSCMISTATEM <br /> ucE=E X c sr a G61 .3 a09 D Ober NUMBER 377923 ExP RATION DATE 7/32 /19 <br /> DOMESTIC WF-LLSAm PLLNc_ General MineraUCol'tform Bacteria(4391)�Dibromochlorapropane(4392)-Arserric(4393) <br /> INTHIDED USE 1 DomeslitlPrivate r IrrigatiDniAgriculturdl 0 Industral C Water Qua6ryMonitMnng t2 Soil SamplinglChamcterizaaon <br /> C PublieWater System <br /> 1rdUrmnI from Owner. Yrater SWem Nave Contact Narfe or Pnone N°nrber <br /> TYPE OF WORK 0 NewW424 C Replacement Wel O Well AhenglonWodifrcatlon D Other <br /> #or wells G SoilBoli s aalbod�5 c Geotechnical 0, <br /> A M <br /> 0,Monila erWells) ng() CeAf7- <br /> D QuHOFS�errfce Well a ODt-Ot-Service Welt RenaMal 7 Cross-Canrreclian Repay <br /> R <br /> D New Pump a pump Re tacement t-Pump Repair II Ralse Well Casing <br /> WELL OON97RUCTT01W ®c <br /> Drilling Method D Mud Rotary r.;Air Rotary D Auger D CaDleTool II Push Point 7 Other , 2� <br /> Proposed Well Depth ft Exzavatian diameter Open Bottom G Gravel Pack/Gtavel Size $l�rreeter <br /> m C 18 <br /> 0 CorMUCWT Casing In diameter f Conductor Casing Depth ft ,Cda1 USN co <br /> Well Casing Diaeter_in ThicknesslGaugeJASTM Schell = ej ]StePlastln 0 Stainless Steel D Other CdS/►p` ,yF o <br /> mUNry <br /> Grout Seal Depth ft 7 m <br /> Neat Cement(24 Ib ba9�'JOgal water) 0 Send Cement sackmi>f1 ga tp red. <br /> D Bentonite(20%solids) :1 Omer MfNT <br /> Grout PlacementMethad D Pumped D Fiee Fall D Other D Retardant)Accelerator(rmme) <br /> PEDESTAL Installed By D i)Tilly D Pump Contraclor D Other <br /> e concrete Pedestal CDlmermions:Width ft Length ftThick in -IChristyBox 0510 Ptpe <br /> Purm 9 Submersibleo Turoina 0 Other HP PumpSel fl Standing Water Level ft <br /> I <br /> HEREBY CERTIFY THAT t 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 IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORf��OPENSATID S. <br /> \ MIN AUNI R VANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> �� y corporate SecretaryA,E &2—,,4) <br /> I <br /> A 1160 10 IV <br /> 1 <br /> I I <br /> D <br /> AN <br /> II CNi 1MVI&ENTAL1 LTH <br /> 7 T-11 Ef <br /> � 1 <br /> b��' I <br /> aw I <br /> I <br /> _L+ ILJI�KML id I I <br /> 1 -44-4-474� i I lit <br /> MENT US O Y <br /> Application Accepted By ate Area-� G� FmPIe]IStt O <br /> Grout Inspection By 0 �M Date 1 SPECIAL Well Permit <br /> Pump tnspecdon By Date Date Z O 0 WAIVER Received <br /> Sol Boring Inspection By Data Constructed Well Depth ft <br /> COMNENTS <br /> PE SC Received ChecIW ArtLouM Permit/Date Invoice# WelltO# <br /> Codes_. Into Cash. _ _ emitted g ice Re uest A - <br /> �a <br /> Erp�]-Cs egtns <br /> X3715172 ala—i1Pr-tP P3is1rt <br /> 0-d tiL9EL9960Z out scalp(]aoueiAand eZO:L L 2l OL 100 <br />