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2666 'ON AVW5 1 SM 'Ol 'AON a1111 paAl ;);� <br /> WELLIPUMP PERMIT <br /> SAM JOAQUIN COUNTY ENVIRONMeiTAL HEALTH DEPAFtnMNIT 186B EAST HAZELTON AVENUE-SWCNTON CA95205-(2U9)4663620 <br /> NON-REFUNDABLE PERMIT CALL 209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> R <br /> JOS ADDtTE55 11881 F Fight- M i l e -Ra aTY/aPLinden 95235 y <br /> 0 <br /> CRoss sTREET.7 a c k T on e Rn APH f)\ v�'o> PARcsL SaE 4 4 LAND USE APPuraTlow 9 ;m <br /> OMERNAME Bob Cademartori PHONE !m <br /> cmFRADDRIss13881 E Eight MIle Rd cmisTATEmpLinden CA 952.36 <br /> CONTRACTOR Purviance Drillers,Inc IpHoNL209-887-3554 j <br /> COr1THACTOR AoDREsu --0. Box 64 CITYISTAT@RIP L inden, C k 95236 <br /> SUSCCUTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATEMP <br /> LICENSE XC-57 u C.-61 u.0-09 u Other NUMBER 377923 ExPIRATtoN DATE 7/31 /1?__ <br /> I <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_- <br /> INTENDED USE Ll OomestidPrivats V Intgation/Agricultural Indusidal L)Vialer Quality Monitoring I.]Soil SarnprmglChararierirsatien <br /> U PUDitC Water OSystem i <br /> ITdieervAtmmwner er 57.1em me n a one u r <br /> TYPE OF WORK LI New Well Replacement Well a Well AlternliordMadirication U Other <br /> n Monitoring Weil(s)__$4ofwells r Sail Boring(s) 0oFbadngs I-Geolechniral is de � <br /> TT Out-OF-Service Welf i'l Oul-Of-Service Well Renewal ;7 Cross-Connecticn Repair <br /> u New Pwnp !Purnp Repla cement G P urrip Repair ❑R21se Well Casio <br /> WELL CONSTRUCTION <br /> Drilling Method -,Mud Rotary _Air Rotary _Auger _Cable Tool --Push Point _ Other <br /> Proposed Well Depth ft Excavation in diameter --Open Bottom G Gravel PaadGravei Size in Diameter <br /> Conductor Casing in dlameter I Condductor Casing Depth ft <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched Steel 0 Plastic [:Stainless Steel E Other <br /> Grout Seal Depth fl 0 Neat Cemenl(94 lb bat;6-10 gal water) ❑Sand Cement sack niirf7 gal water <br /> vi Bentonite(20%solids) ri Other <br /> ,Grout PldcementMethod C Pumped 0 Free Fail 0 Other U Retardant lAecelerafer(name) <br /> PMEZTAL Installed By Et Driller C.Pump Contractor Other <br /> 'v ConcrgTepWestal!-Dlmerisions:VT.dlh ft Length ftThirk In U ChristyBox a Stove Pipo <br /> PUMP _SubmersibleSTurbine L:Other HP_,f-LO_ PurnpSet­_Z_L0 It Standing Waler Level A <br /> I HEREBY CSMFY 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 REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALT. AYMENT <br /> wtzRxE TIDN LAuvs. �CEIVED <br /> lNIMU)N 3iO13 NC NOT] REQUIRED FOR 114SPECTiONS-PLEASE CALL(209)953-7697 <br /> SIGNED ,T1.Ecorporate secreta ,€ l0 3�—iS !Vfl13 205 <br /> t 4QUI ECOUWy <br /> 'EPARTMvrr <br /> I <br /> EIL <br /> VED <br /> I <br /> NL V IL V <br /> 2015 <br /> i I <br /> I ) <br /> i AL HEALTH <br /> IIII IP <br /> VICES <br /> 'i All <br /> r i <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date L j (Z if Area 0,14 Employee ID# <br /> Groin Inspection By Date 0 SPECIAL Well Permit <br /> Pump Inspection By Date :1 WAIVER Received <br /> Sal Boring Inspeclbn By Date Constructed Well Depth R <br /> COMMENTS <br /> PE Sc Received Check#/ Amount pate Pertnld lavoicPS Wei IID# <br /> Codes Info B Cash Remitted Service nest# <br /> /l��/ SIC106 23110031��121 <br /> 'flF1L/RIIAP PER6{ii <br /> 4J3 <br /> anmt2 <br /> Zl'd d9Z:80 �( <br />