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�9Eti'°N A0 atoll paniaDa� <br />WEiLLlPUMP PERMIT <br />SAN JOAwm CounTy ENWRONIAENTAL HEALTH DEPARRAEr/T YaE8 FASTHAZS-ION AVENUE-STOQCTON CA 95205 - (209)4Et B-3426 <br />nn i T Jena% ars 1=YPIRFS i YFAra t onto nATF 1-CC7 IPM <br />CMJZIP <br />JOB AnoRP: sA LCaTtORCROSS STREET Vy APN Ac.Zv {f <br />OWNER NAME 5 o <br />OwN=fT ApoRess D Arv'P 1 �US�lLi1�.-- <br />CerJraACWR Purviance Drillers, Inc PrtoNE 209-887-3554 <br />Cd..wRAcmR AnORESS PO Bog 64 CmrrSTAT'EOPL i n d e n, CA 95236 <br />SUecummkCTOR PHO\E <br />SuecorpTRA cmk Am.iEsss_ Cm 1SrATEOP <br />UmNsE C-57 U, C -sl :1D -M ❑ Oth2ri NwaER 3 7 7 9 2 3 EJLPIRAMON DATE 7 / 31 19 <br />DcmiisnC WELL SAmpumG: - General Mine /Couto rm Bacteria (4391) �: Obmrmchlnmpmpane (4392) -. Arsenic (4393) <br />I TRr3ruEa Use • DsnqS1;TlPnvale D InigationrAgricu1tm91 C Induslnal C Water OuaLty:4 mlOring C Soil SamPtin9/Ch3rac1etiza60n <br />C Pubr.cYrCe" System <br />lfwrAmt(mm Omer Mfer Spleen tam^ Carded Nan= or Poole Number n <br />TYPEOF WORK O New Well C Rapl2cemenl Well O Wen AlterarianlMOdifi=icn 7 Other <br />C N1CnitoTil9WeLI(S) 4 O wets C. SOL, Boling;s) Rafbwn!!5 G Geolathnical 3oraoriNs <br />G Oul-0fService VYeI e Out-0fSemce WeII Rene al 7 Cross-ConneWon Re"T <br />D News Pump i Pramp RepfacemeA C Purnp Re air D Raise Well Casin <br />WELL COAITRUCnON <br />Drltling McUiod C Mud Rctay I- Air Rotary O Auger D CableTeol 7 PushPOirll P. O%er <br />Proposed Well Oeplh it Ex=avaticn in dfarnWer _ Open Bottom G Gravel PaddGravel S¢e `f T <br />❑ConductorCasing indiameler ( COnductorCasing Depth f1 <br />Well Casing Diameter_ in Tnictness]GaugPJASTMSrhed = SleeJ D Piasifc O Stainless Sled 7 Other <br />Grout Seat Depth Tt - Neat Cement (94 (D Dad540gal water) 7 Sand Cement sack ntu/7 galaraler <br />❑ Benlonile(20%soW5) -1 Cther <br />Grout PEacementtdethod F. Pumped 0 Free Fan 7 Other RetardantIAccelerator O me) _ <br />Pr33ESTAL Installed 9y O DrW D Pump Cenvacior O Other <br />Lr Concrete Pedestal CDlmenstons: 11Vidth ft Length ft Thick Fn 1 ChristyBOz O Stave Plpe <br />iEEL 11 R SUbrrrerslltte0 Turbine :1 Olher HIP Pt mp 5� 4�tt Standing WaIEYLeue1 ft t I <br />I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPUCATION AND THAT THE WORK WILL HE DONE IN ACCORDANCE WITH SAN ` <br />.10AQUIN COUNTY ORDINANCES, STATE CAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT VY REQUIRED LICENSE IS <br />CURRENT AND AC11VE VJRH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT L AM IN COMPLIANCE WITH ALL <br />LVO <br />�PENSATION LAW�CE <br />MIN �} NOTICE REQUIRED (F'OR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />u/�x Tf- c r p o r a t e S e c r e t a r rJATE <br />xr <br />MENT LIE NJ,Y <br />Appfic2lian Accepled By DateC711 <br />Groul Irspeclian By ���},� Date <br />Pump I ospecUon BY . (3 �A ) �' 1 lis Uri! V r _� bale 1\ h b - <br />Soil Bodng Inspection By Date <br />COMMENTS <br />AreaBr�loSee lD✓t�L�� / <br />7 PEcwL Well Permit <br />WAivER Received <br />Constructed Well Depth it <br />D <br />a <br />�O® <br />082018 <br />))n( C <br />iMErjjN�, <br />'gRrMe)vr <br />EY.DL'-cn Wins 101170Z <br />Vl:1 iiVJ::PPrni.7r <br />7'd VZ9U2960Z out S-I811i.IQ eOU61A.md d0C:Z0 9L 90 AON <br />