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1ItZ'ON WV61:6 110Z awil paAiaDa� <br />WELLIPUMP PERMIT 1 <br />SAN JOAQuIN COUNTY ENVIRONMENTAL HEALTH DFPARTMENT 1868 EAST HAZELTON AVENtF-STocrmu rA os,>nc _ <br />N-KEFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />ADDRESS. 143110 N. Clements Rd �PLodi, CA 95240 <br />Ss STREET. V41 e' 1 T I Z01(1-; ) l 1) APN 0 5 3 18 0 0 8 PARCEL SIZE-Tt , / HD USE APPLICATIONS <br />IER NAME Rollin' Ranch LLC PRONE209-986-0255 <br />ERADDRESS POBo.x 562 Linden, CA 95236 <br />CONTRACTOR Purviancd Drillers, Inc <br />CONTRACTOR ADDRESS P O B o x 64 <br />SUBCONTRACTOR <br />ADDRESS <br />57 ❑ C-61 0 008 ❑ <br />CITYISTATEZP <br />PHONE 209-887-3554 <br />CITWSTATF121P Linden,Ca 95236 <br />PHONE <br />CiTYISTATEOP <br />NuNB9t 3 7 7 9 2 3 ExP1MTlon <br />7/31/19 <br />uumftbI L:"FLLJAMPUNG: L Cenral Mineral/Coliform Bacteria (4391) L: Dibromorhlnrommriam reaor -, Arcnnin reaoa� <br />... _ _. .. _...• r.........�._ <br />; fENDEO USE ❑ Do-es!iriPn-vate A InigatiorVAgdatftural C Industrial C, Water Quality Monitoring I] Soil SamplinglCharactenzation <br />0 Public Water System <br />!f dlffaren• from Owner. WaterSystem Name Conlact Nam of Phone Number <br />e- ­m rveu u wen NtteraliorVR7DOIhCallon ❑ Other <br />❑ Monitonng Well(s) # of veils ❑ Soil Boring(s) Out tonnes C Geotechnical 0 Dr borings <br />U Out -Of -Service Well ❑ Out -Of -Service Wait Renewal 0 Cross-Conneclon Repair <br />❑ New Pump ❑ PurrD Reotacement n Pumn Reoatr n Q.;- V-1..-__:_.. <br />IUrtlNng MaMod *Mud Rotary C Air Rotary ❑ Auger <br />�l ElCable Tool 0 Push Point 0 Other <br />Proposed Wall Depth 4-72;It Excavation 7in diameter it Open Bottom ❑ Gravel Pack/Gravel Size at diametPj <br />[ ❑ Conductor Casing in diameter I Conductor Casing Depth ft <br />Well Casing lliameter/Aon TNckness(GaugeIASTM Schad ZSD rSLeel 0 Plastic O Stainless Steel C Other <br />Grout Seal Depth It ❑ Neat Cement (94 lb Dag5-10 gal wafal) 0 Sand Cement /0. _3sack mBr17 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placernent Method d Pumped 0 Free Fall C Other 0 Retardant / Accelerator (mane) <br />LPEDESTAL rnstalMd By ib Oriller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal ❑Dimensions: Width it Length ft Thick in D Christy Boar O Stove Pipe <br />PUMP ❑ Submersible❑ Turbine D Other HP Ptanp Set It Standing Water Level ft <br />I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN 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 />WORKERS CnMPrM-RATrnN I AWc <br />MINIMU 24 FYACINCE NQTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-769 <br />nTLECorpor Sectary DATE 12/20717 <br />PER <br />r-afta <br />IrIcek be <br />by Env <br />RE��1V i <br />pOIfN MENT USE ONLY <br />XV <br />}01 a'1joelic tion Accepted By / Date Z 71 <br />HSM pEPAR Grout Inspection By Date <br />Pump Inspecllon By Date <br />Soil Boring Inspection By Date <br />COMMENTS <br />0 <br />a <br />s <br />a <br />CEIVED <br />Area Employee [DO L11LL-W <br />❑ SPECIAL Well POTMA <br />❑ WAIVER Received <br />Constructed Well Depth It <br />PE SC Received ChecM <br />Codes Info (;ash <br />Amount Date <br />Remitted <br />PerrnfL <br />Service Re uest# Invoice# Well IDr1 <br />LAlb7 <br />LAW003 -a- <br />i <br />21 2017 <br />tN IAL HEALTH <br />7SERVICES <br />EHn 41OE mvi6 (�(o �(/ ,5714 WELL UPPERMn <br />£'d VL9£L9960Z T OUB S1911iaQ 9OUeiAind 1260:0 L L 6 6Z 004 <br />