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< T—"kA Sill 'IN Ad6S : E 9102 'ZZ 'Lny nodi p- ianay <br /> WELLIPLIMP PERMIT <br /> SAN JOAQUIN COUNTY ENVRONMENTAL HEALTH DEPARTMENT 1868 EAST HA2ELTUN AwEmE-SToCKTON CA 95205-4209)488-U20 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joe ADDRESS 13695 E Hwy 26 CrtY/nP_L_inden CA 95236 m <br /> CROs sTR@Fr J a c kT o n e APNt0q/--050-/s _ n <br /> 0 <br /> PARCELS LAND USE APPL1CATlON}: � <br /> D,,N� ,,,E Anne Hargrove N.&I6-849-4609 _ <br /> OWNER ADDRESS 13 6 9 5 E Hwy 2 6crtrisTATElnc,i n d e n CA 95236 <br /> CCNTRA=OR Purviance Orillers, Inc. PHONE 2119-887-3554 <br /> L121CONTRACTOR <br /> NTRACTOR ADDRESS P. O. 'Box 64 CrnrrSTATEjZP Linden, CA 9523 <br /> PHONE <br /> tSUSCONIFRACTOR A)DREss CITlISTATEMP <br /> LLcEmE a C-57 U C-451 U D-09 a Other NurleER 3 7 7 9 2 3 ExPIRATroN DATE 7/31 /17 <br /> GEOGRAPHICAL INFORMATION: Coordi notes Y Township_ Range Section_ <br /> INTENDED USE 'O DomeStlGPrivale CI Irrigadon/Agricultural 1-1 Industrial L'Water Quality Monitoring iD Soa SampfinglCharacterization <br /> U Pudic Water System <br /> 11 dlreren rmm oyer. er cme a oma a ore,u r <br /> TYPE OF WoRrc L New Well L Replacement Weli U Weg ARer3tieNModificltion i_'Other <br /> r.Maritorng Well(s) #otwells n Soil Boring(sl ScTboriopa f. Geotechnical 4 C b0nw3 <br /> Out-of-service well Out-Or-Service Well Renewal r'Cross-Cornection Repair <br /> Q New Puma C Purnp Replacement O Pump Repair il Raise Well Casi <br /> np <br /> W�CONSTRUCTION <br /> Drilling Method Mud Rotary L Air Rotary -Auger U Cable Tool _Push Point U Other <br /> Proposed Wel) Depth fl Excavation In diameter D Open Bottom 0 Grauel Pack/Gravel Size in diameter <br /> U Ccndtxtor Casing In diameter f Concluctor Casing Depth R <br /> Well Casing Diameter_in Thidcness/GaugeIASTM Sdted =Steel O Plastic C Starless Sleei collier <br /> Grout Seal Depth Fl L.Neat Cement(94 16 Day5.10ga1 water] ❑Said Cement Sack rrSld7 gal Water <br /> 71 Bentonite(209;solids) r Other <br /> Grout Placement Method o Pumped G Free Fall C Other =Retardant/Accelerator(name) <br /> PEDESTAL Installed By G Duller 0 Pump Carbactor ❑ Other <br /> Concrete Pedestal LDimenslons:Wfdttl ft LengN 0 Tuck In L Christy BOX 11 Stove Pipe <br /> PUMP !Submersible!I Turbine U Other HP / j�- Pump Set R Standing Water Level ft <br /> I <br /> HEREBY CERTIFY THAT I HAVE PREPARED THIS APPUCATION AND THAT THE WORK WILL BE DONE LN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MV REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS <br /> MINIM M 24 U A VANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED Cu �, .,<, T,1, Corporate Secrete <br /> E <br /> �VLDf <br /> 2016 <br /> --"lfii(P'tVq-"qrAL HEALTH <br /> FMCES <br /> RECENE � <br /> AUG 2 3 2 <br /> .JQAQ�M <br /> ;k4 0",A <br /> �7t _ D�PARTMEN7 SE ONLY <br /> Applkalim Aeeeptod By \—TyJ)' (`�'- yJ' 1 Cate Atea 4•'/lyj(// <br /> Employee 10a ("7't� <br /> Grout Irspec5on By Date _ n SPECIAL Well Permit <br /> Pump Inspection By Dale P�D WAIVER Received <br /> Dale 1 b I Constructed Well Depth --i-R <br /> COMMENTS <br /> PE SC Received CheckN AmountDate ParmW <br /> Codes Info Cash Remitted Service Re vast# Invoice# Well IDN <br /> 7- S 141b sJZo07557 _ <br /> 1ID'lZ <br /> 0 <br /> /3 W31AiMPYERNII <br /> c-d «l VJ out sae p(]eouei/vnd d90: 70 ZZ ae <br />