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S911 'IN Md :I 9106 '6 'd;S awil PaA i aaa� <br /> WELUPUMP PERMIT <br /> SAN JOACUIN CoUnrn F-MV RONMEr11AL HEALTH DEPAaxwentr 1a63 EA -r HAZEL'rON AVENUE-SMCKTON CA 95205-(209)468-420 <br /> NON-REFUNDABLE PERMIT CALL(209)963-7697 FOR IP45PECMONS EXPIRES I YEAR FROM DATE ISSUED <br /> .IoaA=RESS 2(}252 Walnut �, G„,.aLinden 95236 <br /> a <br /> CROSS STREE? N Wail U) AP r 0-011- PARCEL Sa Ze—.K)L ..U5E APPUCATICN iJ <br /> OMERNw.r Lawrence Sambado PHOME209-931-2568 <br /> OWNERADORMP,Q Box 461, cmi5TA-,E,z,�inden CA 95236 <br /> CcNTRACT9R Purviance Drillers, Inc. PHONE 209-887-3554 <br /> COUTRACTDR ADCREss P. Q• Rox 64 C1m1S-aT MP, T,11 den, CA. 9523 <br /> SuiucwMAr:rort PHaNE <br /> SimcawTRACTOR AODRess C;TylsTA rF12m J <br /> LicsusE r C-57 L"I D-M u Other Num DER 377923 ExvtR ,,,DATE 7` 1 I 7 <br /> GEGGnAP3tICAL1NF0RMATIGN: C010rdinate9 X Y Township_ Rangy Section_ <br /> IN7ENC6e U5E •DwnesGdPtivate _1;'gaSotVAgrk lrural 1 Industrial L Water Quality Monitoring r Sal SamptinglCharacterzation <br /> IJ PubFe;HaferSyst <br /> 1rd-Itare�ll r..n UZI,am <br /> Ear yzem xnc ...w - .amE ar re cxr <br /> Type OF WORK S Newvveg L Replacement Wel U Well AlterationlMcdification Other <br /> MonitarirgWJl(s)_ Aclwalla 1 SolBartng{s) eofoencas r' Geetechnical acrbungs <br /> Out-CfServiee Well I'Out-OrServae Well Ren Val Cross.Ccrneclion Repair <br /> L New Pump Pump Replacement B Pun 'Re al ! R-Jse Well Casin <br /> "N Ccr,sTttucnoa <br /> OrOting Method t Mud Rotary _Air Rotary _Auser I_Cable Too +Push Point _ Olher <br /> Proposed Well DepP R Fxr-avallcn in diameter Open Bottom 7 Gravel PaGdGravel Size in diameter <br /> Li CcnducterCasing in dianeter I Conductor CasingDeplh FL <br /> lvaq Casing Diamete.T m ThirJenesslGaugefASTM Icheel =Steer C;Plastic E S.aWess Steel 'Other <br /> Grout Seal Depth ft i]Neat Cement(94 tb beg7S10gaf water) G Sand Cement sack nibd7 gal water <br /> :1 Bentonite(2c%solids) :-I Other <br /> Grout Placement Method Pumped F t=ree Fall Other � Retardant)Aecdera ar(name) <br /> PF_DESTAL Installed By Griller n Pump Contradcr - Other <br /> LI Concrete Pedastal LDlmensions:VMdth ft Length ftTfiic< in ::Christy Box d I Stove Pipe <br /> PlT11P 00 <br /> g&Subme rslblet:Turbine t1 Cu er HP Pump SeE ft S4'Intfing Water LeweL It <br /> 1 HEREBY CERTIFY THAT i HAVE PREPARED THIS APPLICATION AND THAT THE WORT(WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIDNS. I ALSO CErrnFY THAT MY REQUIRED LICFME IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS CavrPENSATtON LAW <br /> MINI PS 24 H Fj` V CENCTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> Slav itP�c. TtT Corporate Secrete-44 <br /> I I <br /> I <br /> I <br /> I I I <br /> i <br /> I EI I t ► I <br /> �O <br /> k <br /> PAYMEN <br /> p _ . i��2 2114CES <br /> RECEN <br /> I � , <br /> SEp Q 6 I � I <br /> SAJOAQUIN <br /> 'He"p,O#IItAE1 rAL F 10.f2 T 0.1 E N TeT U E O N LY <br /> Tt-I[FEPARTMA �aV.t�KL'�� r — bl�l l— - /I — <br /> HF1t.1- <br /> Application F.crePteC A Dale Plea C�y't1_VJ`'r'/t Employee tl7e <br /> Grout InsPectarl By Date D SPECIAL Weli Ferrnit <br /> Pump Inspection By Dare .3 WAIVER Received <br /> Ica Boling Inspection By Dae Constructed Well C'epth It <br /> COW WlENTS <br /> PE SC Received CtTerLcw Amount Date PertniV Invoice# Walt 10# <br /> Codes Info B Cash Remitted Service R uest# <br /> (345 (4 11,114, <br /> TO- IIWAP19140775702, <br /> r=.tp<sca 711-/ r- wY;1L fPUVP$FRIk1T' <br /> anaTz r <br /> V-d Oul sl9llu{0 eOueinand ctrl Z ZO�Oadd <br />