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'9cti'°N M10:Z 8[0Z '9 'AON awil PaAI;D;� <br />INELUPUMP PERMIT <br />SAn JOAOU3N COUtarY EVARCNNENTAL HEALTH DEPARTU01T 1 she E:ASTHIAZB_TON AVMU2-S7O0KWX CA 9$205 - (209)4159a420 <br />PERMIT CALL (2091953:T§97 FOR INSPEC17ONS EXPIRES Z YEAR FROM LATE ISSUED <br />ADDRESS J Ctri2lP Ick ✓ 1 O\ 4'i r 1 <br />s5syneeu APN — 1�,O'ILP.... SS D USE APP L1CATION� <br />E33 NNC- PHONE L! — S C7 S c7 <br />E -_ <br />rER ADDRESS J CrrYISrATFIZP <br />TRACTOR Purviance Drillers, Inc PHaNE 299-887-3554 <br />TRACTOR ADORESs F0 Box 64 CrrYISTATFrZJPLinden, CA 95236 <br />SUBCONTRACTOR <br />SUBCONTW.CTDR ADDRESS _ <br />I,eENst; � C -5T D css <br />PHONE <br />CrrY/STATEOP <br />D (L? n omen _277923 ExwRAnDeI DATE 7/31/19 <br />Dams&ncINELLSAmPLrua: C. General KnerallCalfarm Bacteria (4391) -. ObrurnachloropmPane (4392) Arsenic (4393) <br />9mawDED USE ® DornesfcrJPrivale c lafga3anrAgricullurat ❑ Indusidal G Water QuaLly Monitoring ❑ Soil Sampling/Characlenzalion <br />C Publlcwalef Sysles <br />Irdi2enrafmcn Amer. TvaKrSys:em Kane Corned f4wr orPhone Numtw <br />i"E CFWORK D Newr Well C Replacement Well ❑ Well Alteral or MCddicadon O Other <br />❑ MonitoringYYeg(s) i}ofvveOs G So9 Boring($) daf0oi1np C Geotechnical ger °°'raus � <br />L? Out-Cf-ServiceWell C Gus-(Y-SarAce, Well Renewal:) Rr <br />al Cross -Conn ReOair <br />trrllling Method ❑ Mud Ratay r Air Rotary O Auger D CaLICTool -i Push Point n Other - <br />Proposed Well Depth ft E=avation in diameter 3 Open Bottom L GYauel Par.)dGravel Size Ifyd1Zlyeter <br />❑ ConductorCasing in dameter / Conductor Casing Depth ft F&l/.n Q. <br />WeJI Casrng Diameter _ in Thiclmess/Gauge)ASTM Sched --Slee) ❑ Plaslic C Slainless Sleel D Other 'y <br />Grout Seal Depth ft ❑ Neat Cement (94 It bag390gal waled .3 Sand Cement sack n i n gate <br />❑ Bentanile(20%so5ds) 7 Other <br />Grout Placement Method a Pumped D Free F211 0 Other ❑ Re1ardantJAccekM1or(rmme) <br />PEDESTAL Instilled By D Driller 7 Pump Cbnlractor ❑ Omer <br />D Concrete Pedestal CDtmensiorrs: vtfeth ft Length ft Thick Fn 7 Christy Bos El Stove Pipe <br />PU?vP 0 SubmersitileD Turbine 7 Other HP Pump Sd fl Standing VdaterLevzt _ _ It <br />I HI <br />HERE38Y CERTIFY THAT I HAVE PREPARED TS APPLJCATION AND THAT THE WORK WILL 13E DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS 1 ALSO CERTIFY THAT MY REQUIRED UCENSE IS <br />CURRENT AND ACTIVE WITH THE CAUFORNiA COYfRACTORS STATE LICENSE BOARD AND THAT I AAO IN COMPLIANCE WITH ALL <br />Mn ?R�VANCE NpTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 1209) 953-7697 <br />,���/yam r,,forporate Secretar,7A,E —� <br />m <br />m <br />0 <br />b <br />m <br />Accepted By4 <br />EPA TMENT U E NLY <br />TAPPlicalidn Date <br />Area Employee 3DXa <br />Grout Inspection Ely <br />Daze <br />7 SPECIAL Well P@rmit <br />!, <br />Pump Inspection By B'�0 tJ C;yj100ir' <br />�414� Dated <br />:1 WAIvER Received <br />Sol Boring Inspection By <br />Date <br />Constructed Well Depth <br />It <br />COMMENTS <br />8 2418 <br />:NC <br />TUNTy <br />E'd VZGU2260Z out sjell!ja eoueinand d0C:Z0 9� 90 AON <br />