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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> 304 E.WEBER AVE,THIRD FLOOR STOCKTON CA 95202 (209)468-3420 <br /> L L <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED "< <br /> JOB ADDRESS 2091 3 E. State Rt. 12 X15 APNg3-11&D-11— <br /> CITYrzIP Clements, Ca 95227 PARCEL SIZE 400 /�aa <br /> OWNER NAMEEdward Craig Fam lir -'�,j5yats P. O. ' Box .117 .Clements Ca <br /> CITY/'LIP Clements, Ca 95227 PHONE 209-887-3554 <br /> CONTRACTORPurviancer brillers, Ince_ ADDRESS P. O. Box 64 <br /> cYrzIP Linden Ca'i 95236 PHON�liE 209-887-3554 <br /> ITC-57 LICENSE# 337923 EXP DATE7/03 <br /> GEOGRAPHICAL INFORMATION: COORDINATES X_ Y TOWNSHIP RANGE SECTION <br /> TYPE OF WELL: Xl NEW WELL ❑ REPLACEMENT WELL ❑ - . MONITORING WELL# '❑OTHER <br /> INSTALLATION: WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL# <br /> TYPE OF PUMP: XI NEW 0 REPAIR H.P. ``5 DEPTH PUMP SET FI', FIRST WATER LEVEL <br /> . 1' <br /> ❑OUT-OF-SERVICE WELL ❑GEOTECHNICAL# ❑SOIL BORING ❑DESTRUCTION: . <br /> - <br /> INTIWDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION <br /> ❑INDUSTRIAL OPEN BOTTOM WELL EXCAVATION DIA 1 4 3/[CONDUCTOR CASING DIA <br /> Ek DOMESTIC PRIVATE C1 GRAVEL PACK/SIZE WELL CASING TYPE Stell WELL CASING DIA 8 5/8 <br /> ❑PUBLICJMUNICIPAL A ❑DRIVEN GROUT SEAL DEPTH SPECIFICATION . 1 5 6 <br /> ❑IRRIGATION/AG OTHER GROUT BRAND NAME <br /> ❑MONITORING GROUT SEAL PUMPED: ®YES ❑NO <br /> ❑CHRISTY BOX ❑STOVE P>I'E !,�C'� CONCRETE PEDESTAL BY DRILLER: 91 YES ❑NO <br /> APPROXIMATE WELL DEPTH <br /> PROPOSED CONSTRUCTIOWDRILLING.METHOD:'MUD ROTARY x AIR ROTARY AUGER CABLE. OTHER <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY C-57 LICENSE IS CURRENT <br /> AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKMAN'S <br /> i; COMPENSATION LAWS. <br /> E MVM as HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS rr <br /> i Ll" <br />`: 51GNE I' TITLECorporate Secretary DATE:9/1 1 /01 <br /> `i <br /> WIN <br /> !i si <br /> 'I <br /> u +1 <br /> u ! d <br /> i• 1� <br /> !I i <br /> i <br /> J I I I11I1. <br /> II <br /> tl 9. <br /> 4,DEPARTMENT USE ONLY Q(p <br /> Application Accepted B D � EMPID#ate a Grout Inspection By� Date Pump Inspected By _"�'' <br /> p� <br /> Date//,, ' <br /> '4 <br /> Destruction Inspection By ate <br /> COMMENTS: <br /> a <br /> PE SC ' AMOUNT; CHECKRECEIVED DATE PERMIT/SERVICE REQUEST# INVOICE# ' WELL IDq <br /> CODES INFO REMITTED.i BY <br /> 00' <br /> �i5 l 1 f <br /> F <br /> �F38' DS 'lSay <br />