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6� '°N NVH : 1 01H '9Z 'gaj aWl j paAI ;D;� <br /> VVELUPglMP PERMIT <br /> S0..Y JOAamu COUwYEAvmDNJAENTAE.HEALTH DEPDRYMENr 1066 FAST FtA=-rn,v Avetuiz-STo=Tom CA 95205-(209)4M-3A D <br /> NQf4-REFUNDABLEPEFWU CALL 209 353-7697FOR1N5PECTF0NS EXPIRES iYEAR PROMDAlEI55UED <br /> JDs ADDReSS <br /> 1763 5 Hew' Cm Linden 95236 <br /> -L /,? � <br /> OpperopoliS r. PNP,��S _La�nllsEAPPucATtoua A <br /> 06VUERt� Ru�r_C TA1_P�-6ten�7 /�.. PHm_09-404-91 00 <br /> 0wRE-� AoDRess 1 7 6 3 S Hewitt crtYrsTA1,=mp Linden C'A 95,236 <br /> CONTRACTUR Purviance Dr-i llers, Inc PHaus 209-887-3554 <br /> CWTMACTOR ADCM�SS ?0 Box 64 C IVSTATEf2JPi n d e n, C A 9 5 2 3 6 <br /> (ISUB=OMALCTLR PHOLS <br /> {SLJCorJIRJ1CIDR ADDRESS CFTYISrAT92) ? <br /> !`Lcr_.45E X C-57n C-51 :ID-aa 0 Otho NUUEER 3 7 19 13 E�manotJ Owr 7/31 /19 <br /> Dos�Es=f41ELLSAStPLWm General M ripjAICOlffOFm Sacteda(4391)L DihmmochlMPMpane(4392)=AmenIC(4393) <br /> Ith7ENDED USE 0 DatneSdd?fivaIe hrgationlAgriculWtal C Industcal C Wa'arQuzLtyManilaring ❑SeilSampFingfCharaderimGon <br /> 1 PubicWaletSysletn i <br /> L'd:lArart[vm Ovmec sraerSysi:m h7ne GwErrY h'arr er Plroec M.anJc <br /> YPE 0;2WGFI 0 NaVWeil C Replanernmt Well L WJI AtIera:inNCdCdiIrg50n 3 QIIrLT <br /> n Mcrraering Wefts) Cof w-dis G SoIBoF`•ng(S) Geotec"cal =urtwr[rrs <br /> C Out-OfServm Well ^_Oul-OfServiee OJelf Remasal 7 CraSSCo=F!rl7cn Repair � <br /> 0 NE-al PUMP C Purnp RLPIZCentent Pu 7 Repair RaLseVVelf Casing P <br /> 1 KNELL Loms7Ru=a:J <br /> I <br /> `Drillirm Mekl;od 0 Mud Rotary r_Ar Rotary OAuger 7 Cable Tool 7 Push PDI nl t-1 Oater <br /> (Proposed Weff DepLh f. Esavaticn L7 diameter =Open Bottom G Gravel PackrGravel San, in d:unele �® <br /> C ConductorCasmg indlameW J Cmda--t3rCasin9Deplh ft r9 <br /> Well Casing DEm.ater_in Ga <br /> Thidmess1ugPJAST31 SrhB ed =Steel Pbdic C Stainless 7 <br /> Slee) Me, . 1 4j <br /> Grout Seal Dep U1 ill D Neal.Cement(9%to bacr 10 gal vraL-4 al Send Cement sack rnhl7 pp9 <br /> C Senlorlita(ZOIAsF7llds) -:101h ts QU//V <br /> Grout Placement Method G Pumped 0 Frre Fall 7 Dltrer C R-tadanHA=eieratar(ftzme) '04141CC)(/ <br /> PEDSsTaL eretdseson_ aLFRM <br /> neprraiCDknenns_-Mdmente ItThick in aChAstyBox DSLvvePipe N <br /> Punta Submerswea Tumine D Olne,- HP Pump Std It Slardng Water Levu It <br /> I I., E Y C:ER 3FY THAT I HAVE PREPARM THS Ap?UCA-n0N AND THAT THE VJORK VC1LL BE DCNE IN ACCOROANCE WITH SFW <br /> JOAOUIN COUNTY ORDINANCES, STAT LAWS, AND RULES AND REGULATIONS 1 ALSO CERTIFY THAT MY REQUIRED UGE745E IS <br /> CURRENT AND ACTiVEE'AM THE CALIFOMVA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN CChMPLIANCE W TH AL <br /> WORKERS VAPENSATION LAWS. <br /> ( M11N )UI9f 2 DVAIIICE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(204)953-7537 <br /> S, corporate SecTetar ,E / <br /> IiI 1 I1 f <br /> I <br /> II II I I 11 i <br /> I I I I I IIl <br /> 11 1 , 11 I I I I I I I I I I Li I 11 <br /> I Ililll I l I L I I ! <br /> I I I I II AT7 <br /> I i <br /> 1 ! { I I I l 1 I I r t <br /> ! 1 I- <br /> I I I { <br /> I I it AN 11 ll ! ! <br /> i I I I I I I <br /> f II I <br /> I II ! <br /> III 1 I <br /> EP RTMENT SE ONLY <br /> t <br /> Applin<ticm A=eptcd By OAIs Ierpy <br /> Grout inspecEon By Date PPECIAL W111 Permit <br /> Pump Inspection By I�'1-t\� '� ��`laOrS �V`C>t�1 Dxe�1'-11(\ , 1 1 G�'� ❑ WAIVER Received <br /> SDI]Boring fnspertion By Dale Cot truUed Well Depth tt <br /> COMMENTS <br /> PE Sc Received ChecW Amount eer'tV Invaice:! Well"w <br /> es_ .. Info -- _ _. h. .._ -.Remitted Date I Service ReIIuest# -_ - -.- <br /> .. .I---- A 17 77 1 I 'SMI I - <br /> f-w <br /> I <br /> EHD�.5 earns <br /> t'd t'Z9U2860Z OU1 S.IeIII.IQ 8OUBIA)nd eZ`:N 6L 9Z 9a-� <br />