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0082 '"N AVK : -1 M/ 'H 'Ina IWI J P;Al ;�;� <br /> WELUPUMP PERMIT P <br /> SAN JOA IN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HATELTON AVENUE-STOCKTON CA 93205-(209)46836.20 <br /> NON-RE FUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JaeADoq 14515 Raker Rd / Cy�P Linden, CA 95236 T <br /> CROSS 5 EET Jack Tone Rd APY /- O �� PnrtcEL ralZE ry -/ LAND USE APPLJCATONR <br /> OWNER ME Daniel & Paula Puryiance Fa..:nn; --�-T�rl-uaitoNE 209-887-3554 m <br /> N <br /> OWNER AC DRESS P .O <br /> `J.B ox 1 3 2 1 CIT7/s-rATE0P Linden , CA 95236 <br /> CONTRAC7DR Purvianc(1- Drillers , Inc PHONE 209-887-3554 <br /> CONTRA ADDRESS P O B o x 64 CtrnsTA-1ElZ P Linden,C a 95236 <br /> �SUBCONTR04CTOR PHONE <br /> SUBCON CTOR ADDRESS CIIYJSTATEIZW <br /> LICENSE [ Gsr D C-61 U D-09 D otherNUMBER 3 7 7 9 2 3 „u,,,o„DATE 7/3 1/1 9 <br /> Domesnc WELL SAu.PLiNc:L General Mineral/Coliform Bacteria(4391)E Dibromochloropropane(4392)=Arsenic(4393) <br /> INTENDED SE ❑Domestic/Ptivaie Alli igatian/Agricultural O ttldustrial 0 Water Quality Monitoring U Soil Sampling/Characierization <br /> 0 Public Water System <br /> Ifdlnerern Imm Owrer. Waley Sysharn Name Contact Nome ar Fhore Nuwbw <br /> TVPEOF ORK Y New Web C Replacement Well D Well AlteratiONModification 7 Other <br /> n Moritoring Well(s) A of wells 0 Soil Boring(s) SM be"r'gs 0 Geotechnical it orborrngs <br /> ❑Out-Of-Service Well 0 Out-Of-Service Well Renewal ZI Crass-Connection Repair � <br /> O New Purnp nPurnp Replacement O PLanp Repair rl Raise Weil Casing <br /> WELL CON TRUCnon <br /> Drilling M thud 0 Mud Rola Air Rotary C Auger D Cable Tool 0 POstr Point U Other <br /> Proposed Nell Depth C�R Excavation in diameter IP Open Bottom 0 Gravel Pack/Gravel Size in diameter <br /> C Cohductor Casing n diameter / Conductor Casing Depth R <br /> Well Casing Diameter V1h;in Thickness/Gauge/ASTM Schad ./ff,�- t Steel ❑Plastic U Sta nless Steel ❑Other <br /> Grout al Depth S1nft ❑Neat Cement(94/b bag6-10gar watao p Sand Cement 10. 3 sack rr>k/7 gal water <br /> U Bentonite(20%solids) O Other <br /> Grout Pla ament Method E Pumped ❑Free Fall O Other ❑Retardant i Accelerator(name) <br /> PEDESTAL Installed By IN Driller U Pump CDntractot ❑ Other <br /> n Concrete Pedestal ODimenslorls!Width ft Length ft Thick in ❑Christy Box ❑Smve Pipe <br /> PUMP C Submersible❑Turbine 0 Other HP Pump Set ft Standing Water Level ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL SE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS- 1 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 ALL <br /> WOKERE NSATION L <br /> IN 22 O; AD <br /> NCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED f - �GG�- f� T Corpor Sectary DATE12/21/17 pqY <br /> -14*,qit <br /> �VFD <br /> b cryoFpgR CO. <br /> N�Y <br /> FN <br /> M <br /> M. O M <br /> I i ;ao m <br /> z <br /> �m� c,o IIS <br /> s N <br /> n= O <br /> E RTMENT SE 10 LY y ti <br /> Appli r�[tion Accepted By Date A� EmployeeID#lI _ <br /> G ut Inspection By Data IJ SPECIAL Well Permit <br /> PUTp Inspect on By Date ❑ WAIvER Received <br /> Soil Borng Ins edlon By `Date Constructed Well Depth R <br /> COMMENT <br /> PE SC Received Checl#1 Amount Permit/ Invoice 4 Wet1 IDN <br /> Codes 1 o Cash Remitted Service R oast <br /> EHD 43-05 MIMS aT-, t',rELLMUMPPERMfT <br /> d «l au saa a eoueiA.ln e oa <br /> Z' t�L9`;L8860Z I II. D d 9Z�6 L L L 6Z D <br />