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Feb -01-06 05:02P P. 01 3° VrELL / PUMP PERMIT 7AN JOAQL4N COUNTY ENYIk ON IrN"1'At. HEALTH DEPARTMENT 304 F WLSER AVET° rL - STACKI (IN CA 94202 - (209) 469-3020 v'nN_RkCSINDARLE PERMIT CA1.1. (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB AouRFcc 600 Hewitt Rd_ . CITY/ZIP_.. Linden _ Cawssratcr PPero Co olis Rd. APN IP7-o2C,-03 PAK(EI.sIZL_ .7q - P OWNEk NAME Collett's Board & Care Home _ PHnNE 53�— 1625 W. Whitmore CD'y1STATPJLIP Modesto) CA 95356 OWNER AUURE.eR - COrWIRACTUR Purviance Drillers, Inc. PhOVE 209-B87-355 - CITYIS"1'ATFIZO. Linden, Ca 95236 _ CONTRACTORAVURESS P.O• BOX 64 — - SI111CONTRACI OR SOa(nMItACTOit AUItRES.e Llctnjt me -47 0('-61 ❑ .,__ PIInNt CO Y)STATEW It i ❑011ier_,__ _ NUNIngR 377923 LXPIKATInND,NIE j/31 /05 (;E(wKAPHICAL INFORMATION: CYRrdlastes Y INrENutu USE M DOmestl L/p(Iwate ❑ lfflgation/AgficUIWT1111 ❑ Industnal O Public Water System If J�n'urtnl Rom Owror �u�ra'cn— _ Tnwnshlp —_,_ Runge Water Quality MOMEOring 0 SmI S �— —. oawu. auu orP nh�Sei - Section -haracleri coon Ta'et OFWORK ONCWWell ❑ Replaccmpnt Well ❑ well Alteratinn/MuOJicatinn ❑Test Rule 001her '- - numoar u(uum,s — numhrrarwu' 0Soil tfurin sBO numner urounn� ❑(;c0iu 11olcal s ❑ Mnniluring Wdl(s) _- —..— -- ❑ Well Delimitation ❑ Out•Of-Service Well ❑ Out-OI-Setvicc Well kene.al O Nic. pi ❑ P 1P Repl cement E Pump KOPaIr u l inza-s,onnccuun ncpm.. WELL CUNSTRU[TIUN Drllting Method ❑ Mud RM21Y (3 Air RuturyN.,` /;< O Auger ❑ Cable Tool d Push Punt O Other Proposed Well Depth :;H. ;CAcAatiivlTT in diumetef ❑Open Rnttnm ❑ Gravel Psck; Gravel Size --- in diameter _ r.l- 1 O ccuc r4;istrly _�. •. in d-lu cter I Conductor Curing Depth OTJ Well Cadug Diameter int' 1�'12t lyknMV(reugdASTM Sehe O SIWI ❑Plastic O Stainless Steel ❑ Other Crou1 Seal Depth_ Yt ❑Nem Pnwnt ('J s -/fl gu/ wwlrr) ❑ Sand Ccmenl _ _•urA m:x / 7 gal wine. ❑ Hentunile (204: sobds) O M Wb %rr ulids _ % Nume ., 0 Spcca un File ❑ Specs Submiucd Grnul Placensent Melhud 0 Pumped ❑ Free F' I _ _ _ 0 Retardant / Aoeelcprnr (name) PLUEST-V Llualled Uv ❑UrineXPIPu PC tractor ❑Other ❑ Concrete Pedestal Dlmena a: Width 11 Lengtb__ 11 '[hick _ in ❑ Christy he% O Stove Pipe PIINIP IRSubmen,iblc it OI - P P t ' t 't tan cvel lY _ Wtl.l. DESTk6CI ION ❑ pen Hntbom ❑ ;ravel P ck ❑ U eased ❑Other __ _ - __ Well Diameter it, Total Depth _ __ R Depth to Water Il ❑ Casing to be Perforuted fruin H w ___ 1) Sealing Malar;al ❑ Neal Content (94 Ili hug IS -g0 go/ wort,,) Cl Snnd Cement va,!k,nix f 7 gal wale( ❑ lienlumle Pellcts ❑ Hemumie (20%snlids) ❑ Manufacturer Spec %solids .,_% Name _ ❑ Specs on File 0 Spew Submitted Placement MOlrod ❑ Pumped O Pree Fall ❑ Other ❑ C'umpleic with Mushmum Cap _ ft blow grade ❑ C'Umpletc to Fmoing Surface Pad I IIERERV CERTIFY THAT" 1 HAVE PREPARED TIIIS APPLICATION AND THAT THE WORK WILL DL DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE I.AWS, AND RULES AND RECULATIONS. 1 ALSO CERTIFY "THAT MY REQUIRED LICENSE IS CURRENT AND AC'T'IVE WITH THE CALIFORNIA CONTRACTORS STAFE LICENSE BOARD AND TIIAT 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. �4►9fftilMUN 24 R ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209) Q53-7697 sten mea </ Tlll.tCOrporate Secretary_..— DAfLB/10/04 Application Accepted By — Groul Inspection dyJ' Pump Inswilun D� Destruction Inspwli0n By _ COMMENTS (J 'Y V- HENT t]SEOI%IJV I [� Dole O �J .�.__ Arr:a_�-l�_ Fn,pinyce lou _J_—IY YL 1/� Dale ❑ SPECIAL Well Permit Date 1�%`Zz/G O WAIvER Received Data, —, Cunurueted Wen Uup(h (t PE SC Received Codes Coder Info By t, Checkll/-1 Amount Pau as Remilled Permit/ Scrvlce Request A P Well IDA 3. k-2- CCO OTJ , Q ?y �. FHD w1-07-7XIA _