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lW 'ON NRZ:Z 9102 'qaj -LJ ll p;A I ;) <br /> WELUPUMP PERMIT <br /> SAN JOAQUIN COLNry ElMRONKCNrAL HEALTH DEDARTwE- r 1868 EAST HAZELToNAVCME-STOCKTOU CA 95:05-(2")468-1420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Q09 ADDRESS 17325 -F Si ht Mile Rei 95230; <br /> IIS <br /> .__ 9 — _._ clrzld.inden _ , n <br /> chess STAEEr Duncan Rd _ APN G'6) l Ov((> PARCET.SvE�'�•�� -tJwo USE APPucAno++z a <br /> CMNF.RNAME Webster Williams _ PHo,21 9-541 -1 51 1 <br /> CvW rctAnLprss2363 Panorama T R uT.rf5TATErz„La Crescenta Cz1 91 211 4 <br /> COUTRACIOR Purviance nrillers,inc PHoNE209-887-3SS4 <br /> CCNTRACTOR ADr RESs D O• Box 64 L+ <br /> CITTISTATEMP i ne en, C Z1 95236 <br /> (SUBCONTRACTOR _. _ PHOME <br /> SUBCONTRACTOR ADDRESS CITTISTAT6ZP_ <br /> LIcEvSF (XC-57 C-61 D-0j otter --- Nu;ntdETt 377923 EJNIRA710N DAr 7/31 /17 ! <br /> GEOGRAPHiCALUFORMA'ION: CoordinateS X Y Township_ Range Semon_ <br /> IvMMSD USE ❑DOmestic/Pri mto etr IfrpmSonfAgncuilaal -I Induslral 7 V'LAer Quality IJontertng Z Sail Sarrp:ingJCharacterization <br /> L Publ.c.Water Sysem <br /> tl_Rcre9 hon Owner � on.em rte __ �- vFi�nV� <br /> TyPE OF WORK LI New Well �_Replacement WeF L Well AseraboNN'ediration U Other <br /> Nbnitonng V':eJl(s) IC oI'wtlls n Sod Born ro1°'O""s' set oorm)s <br /> g(s) " Geot-chn%al <br /> Out-O(-Se ioe Well :Ow-OfSeNce V.10 Renewal ^Cross-Connectin-1 Repair <br /> _ C:New Pump APtimp RecLxemeot - PLmp Repair �.RaiSe~I Casing <br /> 1WEI_L CONSTRUCTION -- <br /> Drilling Method v btud Rotary ,_ Ar Rotary ,Augef Cable Teel ;PUSn PCim J 011ier <br /> Prcpoacd wou Depth It E=ravatior in diameter L Open Bottom _Gra P3WGravel Size in ahmeter <br /> L Conductcr Casing in diama_,er / Conductor Casing Depth _h <br /> Well Casing Diameter_in ThickneSS/GaugeIAST I,Scred Steel C Plastic =Stain,es3 Steel -.Other _ I <br /> Grout Sraal Deplh fl :Neat Cement(94 Ib Gag--To gal Ovate C Sand cmnenl Sato rtiw7 gal water <br /> Sentonie(2oh solids) 7 Otho -- <br /> Grout Placement Method C Pumped :1 Free Fall 0 Other =Retardant I Pcce*Mor(name)_ J <br /> PE7E3rnl Installrrd By O Dn1W_r O Pump Contractor - Other _ <br /> U Concrete Pedestal Olmemions:VMth _ B Length <br /> _It Thick n L ChnstyBak U Stow Pipe <br /> [Prot- Sutircrsioief Turbine LI Olhcr HP /-'D Pump Sat 41 4 Sanding N/ate Leel R <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS,AND RUL-FS AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LJCEAISE IS , <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE. LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> YJORKE ENSATION LAWS. <br /> MINIIWU =HOURNCE NOFICE RECUIRED FOR INSPECTIONS-PLEASE CALL(209)953 7697 <br /> SIDrim ��v�-�. Trn Corporate_ Secretary 23-/- �AYMENT <br /> FFDENED <br /> I 092 <br /> 016 <br /> AQUru <br /> — I - - Eh1)ROtiF M COUk7y <br /> H D EJr" ( <br /> I f <br /> - -- - Aar <br /> F 'r <br /> I I I I I I h <br /> I I <br /> ENVIRI I _ <br /> PEM ffli } � <br /> t <br /> - - i <br /> LT ' <br /> - I <br /> - <br /> �DEPARTMENT U.SE ONLY <br /> Appli:nlion Accepted By / -� ✓ Date ( ' `iv Prza�, ` ` Employ- <br /> Gr^_ul Inspec:rcn By--f <br /> nsPnCzte / _ D SPECIAL Well Permit <br /> f V / WAIVER R@Geived <br /> Pump l �?G "u GY' __ Celle <br /> Scil Bering Inspection By _ - Date_ Constructed Well Depth _ R <br /> COR1L1et47S <br /> PE SC ReceivedhC eco Amount -- Permit/ <br /> Codes Info By Cash Remitted, Date/ Service Request 011 <br /> -I Invoice p WeII IC# <br /> 6 -- —� - <br /> CIIJ.13Y 0,�7�� /\ N.•!L 1�l LR'P:A'JR <br /> g'd d9lvOl L0£O deS <br />