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Nov 04 00 10:40p <br /> P.3 <br /> SAN JOAQUIM CoitwrY WELUPUMP PERMIT <br /> ENVIRoIusl—ALHEALTH DEvnRnlattT <br /> NON-RERINDABI.E PERMIT i 1889 EXST HAZEL ON AveNut<-S ncKTON CA 9SMS-(249)4663420 <br /> CALL 209 9S3-7697 FOR 1NSPECnoNS EXPIRES 1 YEAR FROM DATU 1SSUIM <br /> -�AW� 1 7520 N. I Jack Tone Rd <br /> CROss STR � i //�� ,/ c Tvdm Linden 9 5 2 3 6 m <br /> APN_fl.�7i- PARCEL SIZE u'9}LANn uSE APPucwrtDx tt <br /> �tNAM Ray Colline <br /> OAWMA2oljss 1257 Jenevin Ave <br /> CUYISTA-W&P San Bruno CA 9 6 <br /> L�'7.KrRACTOR Purviance Drillers, Inc <br /> P. O. Box 64 09-$B7— <br /> COMt:AcrORADI=IE9S � inden, <br /> SUsccNrtucTQq C"ISTATVZP <br /> ' ------------------------ <br /> S��TRACM;t ADDRESS PHONE <br /> CTfYi$TAT1:'/jJP <br /> IJ�Nse X F57 c c s1 c D-0� ❑ower Nenrsr 3 7 7 9 2 3 7 3 15 <br /> 0 <br /> `� GExru7ii:..AL tHFORUAr1oN: -- FJ�lR11TON DATE <br /> C oordirrat s x Y <br /> 'Dt0 us9 Q DomesttdP g Townsltlp_ Rango Seetion__ <br /> rhmte rri a11on(q nwttur+al ❑In ligirial ❑WaterQuairy Mon!forlfig C Sot!SarnpYinWCheraGer¢ytlon <br /> 4 0 upUbcerm�aterSyslem <br /> aa„o,.ner, <br /> TYPE OF LYOWt w Wep D lam <br /> o -- <br /> 0 h Repnen! e.l 0`A'61Alterahonnllodrficatlan Q Other, <br /> Q Monftrniny VVe1l(s) *.f.Yrel Ls D SOLI6onng(s) aorbonrgs <br /> Out-CtSe i Q Goo'.00hnlml seteort'�9s <br /> +viae Well O Out-0r-Service Well Renaval ❑Cro s.Conn ' <br /> 0 1, Pump Q Pu. Re la cement Q nr Reoair �On Repafr <br /> Wa1C NST2tt O 17 Ra Se Vlrell Cesln <br /> Dnlnng Method a Mud Rda Q Air Rory 0 Auger r-Cab7c Tool <br /> P*epos�d Well De Ptit ��� R caavatien /9 Z- Q Push Point Q O1Mer <br /> in diameter W 01 en BOWOM D Gnnr ?PaddCG avec Site in diameter 1 ` l ,•r: <br /> ❑Candaetori wing indameter I ConductorCasuglkDpt_"_ j <br /> Wel)Casing Dlama ter �J(n ltildatOWGauge(ASTtd Sethed -p ft <br /> Grout Seal Depth���R ----�L— t Steel D Plastic: Q Stainless Steel D Omer <br /> 0 Neat Cement(94 Z 099'540 gat kVer) 0 Sand C.1 .. t o.J .erlr <br /> Q 8anlDm to(2M Molds) D otfier satirl7 gal vra]er N <br /> Qro ut Pla cement Method aPaan <br /> DedD Free Fal 0 Other--- C alit 1A=01st-lor(name) <br /> PPSTAC JIM flodBy a Driller D PampCoatraCtor ❑ Other .1{' ' d •� <br /> 0 Cancretel' <br /> P'edesbl l'_Dfmanclan----- R Length 11Thirhn G Ch <br /> A. <br /> `•C�''(z .�' <br /> risty Box ❑Sinv2 Pi pe i <br /> n ❑SubmensihlaD Turbine C Other HP — n. � <br /> 1 HEREBY CERTIFY THAT 1 HAl2 PREP Pip R Standury LValerLevel g , <br /> ABED Tff.S APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE LtflTy SAN <br /> CURRf N CoUNWA ORDINANCES• STATE LAWS, AND RULES AND REGLtLATON3 1 ALSO CEFi77FY THAT fNIY REpUIRED LICENSE LS (G <br /> CURRENT AhfD ACTIVE WITH T7tE CALJF�Jf3nA CONTRACTORS STATE LICENSE BOARD AND THAT I ANA IN COMPL AED PATH ALL <br /> wo WENSATIDN LAWS. I, <br /> Ml UM 14ANCE NOT,JCE REQUIRED FOR INSPECTIONS-PLEASE ll' <br /> LEASE CALL(209}953 697t;•' • <br /> E TFfLE Corporate 5ecre lay L/ <br /> I I <br /> I i <br /> IVF6 <br /> ?Oi4 <br /> OME C�IjNry <br /> EPAF]T��r <br /> DEPARTMENT USE ONLY <br /> i1PDJca9Dn Axea(1ed 69' /�/ e� -�f <br /> Grout ins <br /> PedfanBy Date ZZ Area D�� ! ! Empboyee®3 L LD W <br /> PUMP Lisped an By D>tD O 1 SPECIAL Wel!PerMtt <br /> sof,Eoting inspection 8 --- 0 WAS Received <br /> C-CMWK7-S / Dar C0n$VJeted Wall Depth R <br /> V _ <br /> Fl� <br /> SCCh"JW AatotmtCNo Permit( <br /> DataRbmitigd Service Requesfx j IrrvoicpS We111DG <br /> 4gO ��9 tic}, 22 Int �;0 <br /> E�MA <br /> .W1z <br /> �+a:evivr rcton <br /> Received Time Apr. 7. 2015 3: 06PM No. 8478 <br />