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`I.•'�(��\ Sw+� 1-[i✓ OSw� 5911 '°N NZI :S 910 Z 'daS awi j paAlaDaa <br /> WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTN DEPARTMENT 9863 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468.3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 9 YEAR FROM DAM ISSUED <br /> Jc®ADDREss 20262 Walnut jRl1)f, crrz Linden 95236 a <br /> Cp059 STREET N Wall R D ADN U r PARCEL$IZEj ANO Uss APPUCATIM k <br /> OWNER NAME Lawrence Sambado PN,,E209-931-2568 <br /> OWNER ADDRESS P.0 . Box- 4-61 cm sTA REaL i n d e n CA 95236 <br /> )CONTRACTOR Purviance Drillers, Inc. PHONE 209•-887-3554 <br /> (CONTRACTOR ADDRESS P- 0. ROX 64 CTTrIS7a,FmP Ta inden, CA 9523 <br /> SUSCOMMACTQR PHQNE <br /> SUBCONTRACTDR ADDRESS CITYISTA,EIZap <br /> �LICFNSE Lj C-57 L C-61 L D-M a Other Nu.. 377923 E,,A,toN DATE 7/31 /1 7 <br /> (315CGRAFNICALINPORMA71ON: Coordinates X Y Township_ Ranges Section_ <br /> INTENCE0 USE to DOmeSUCIPRVate _IrrigaSONAg cultural 0 Industrial L Water OualityMonitering ^Soll SamplingtCharacterizalion <br /> i..+ <br /> R IJ PUSIie Water System <br /> , ■ If d�eaRnl nomOmer, a;ar ysem .Te art®ar re moor <br /> �kai�j■ f <br />•� _ TSQ OF WORK L New Wel L Replacement Well a Well ARerdtioNModilication L Other <br /> �- CA 7 —,MDnitorirg Wal(s) A W wells n SOA Bairixg) a ortwe ps r' Geottechnical acrbPrrgs <br /> Out-OfService Vl2e I'Out-OfService Well Ren vest "'Cross-Ccrrtec4on Repair <br /> �y �L C NeN Pump Purnp,Replacement a Pump Re ai i _Rase Weli Casin <br /> C NSTRUCTION <br /> 'p O g Method =Mud Rotary L Air Rotary :Auger i'Cahle Tool _Push Pcint ! Other <br /> rte+Ptosed Well Depth. R ExcavaUcn_i<n tliameter _Open Bottom C Gravel PadJGravel Sze in diameter <br /> u Conductor Casing in diameter I Conductor Casing Depth <br /> ■ R <br /> -Otdll Casing ❑iamete:_T ThirJoless/6augelASIM Sched C Steel G Plastic C Stainless Steel 'Othrr <br /> rout Seal Depgi R 0 Neat Cement(g4/b bagl5-f0gat"flr) C Sand Cemen: sack mbd7 gal water <br /> E n Bentonite(20%solids) :T Other <br /> a­*­,,,i­ CZ Grp@ Placement Method 0 Pumped C Free Fall =Other ;Retardant!Accelerator(name) <br /> C PEWSTA Installed By Crider 0 PumpConlydcler = Other <br /> !_I Concrete Pedestal LDInRensions:%Aldth ft Length ftThict in U CbristyBox lI Stove Pipe <br /> C P r0 Submermblei.:Turbine LI Other HP pump Set R Standmg Water Level R <br /> Uj1111..N.•••.••• FWfBY CERTIFY THAT IF HAVE PREPARED TfitS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> [A- . UQADUIN 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 ALL <br /> .R <br /> WORKERS COMPENSATION LAW <br /> MINI M 24 H V CE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> sQ1 T,,E Corporate Secreta <br /> I � f <br /> -4AN 11 <br /> t <br /> —I <br /> I <br /> I <br /> 2016 <br /> PAYMENkL HEALM <br /> CES <br /> RECEN <br /> Ek— <br /> SEP #1 <br /> - <br /> SAN JOAQUM <br /> EMIIRONMENTAL E A R T U E N T U o E ONLY <br /> TH DEPARTMEhIT <br /> HF�L Application A cagt Dale Pisa'`�'T'T— Employee 093f o <br /> Graut Inspeclion By Date_ 7 SPECIAL Well Peffnif <br /> Pump Inspection By �a:e .3 WArvER Received <br /> Scl Boring ins :tion By_ ?a: . Constructed Well De;ah <br /> CO6aVENfS Iz� < C1 Aa <br /> PE SC Received Check!/ Amount Date Permit/ Ipvoiceo won 10# <br /> Codes Info H Cash RemittFd Service Request III <br /> 410,"'5310/14# 914077670Z <br /> .EHD<3.06 N/�.iL?U4`.P>FAM1tIT <br /> d tL9£L9260Z oul sjellua eouelnand et,L:z ZO£OJdy <br />