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890ti 'IN AV[S: l l 8loZ Dnd 11111 paA l;);� <br />WELUPUMP PERMIT <br />SAN JOAQUIN COUNTY ENV1RommFNTAL HEALT% DEPARvuNT 1968 EAsTHnzrL'ycu AvENUE-S-mcKTON CA 95205 - (2.D9)458-3420 <br />IYON-REFuNDAsLE PERMIT CALL 209 953-7697 FOR INSPECTIO EXPIRES 7 7 EAR I=RUM UAI t IZF�utL <br />JOB ADDRESS 1 Iii T) P/` rye s Rte. Z/ CITYM o d i 95240 <br />CROSS STREET Zell, 19A— APPARCEL SIZED. 0 LAND USE APPLICATION <br />OWNER NArnE J .'i'I <br />Q G PHONE inA—Z1n 1,—��J.� <br />.ER ADBR. 213 2 5- B e v r i e s R d CmrISTATVZIP L O d ID C A 95240 <br />coNTRAcroR Purviance Drillers, Inc PIIo..r209-B87-3554 <br />CONTRACTOR ADDITTSS PO Box 64 CrMSTATEMPLinden, CA 95236 <br />SUBCONTRACTOR PHONE <br />�SUBCONTRACTOR ADDRESS Ct;YISTATEOP <br />IUCEIVSfi Y,-U9o other_ 377923_ E]pRARON Dat£ 7/31/19 <br />G57 U C-61 <br />Dcm smc(rVFLLSAmPuNG General MineraUCalifann Hecletia (4391) C Dibromachloropropane (4392) -.-Arsenic (alas; <br />INTENDED Use D OomestidPrivale ® InigationfAgricultural G Industrial G Water Quality Monitoring D Soil Samp6nglCharacierization <br />D Pubfic Water System <br />Water SKS t.2rm Gon:a12 Hams or Prton.: Numb <br />tf diffmnl rrom Owner <br />TYPE OF WoM D Nevi Well L Repta ement Well C Well AtterdtiordModifrcation 7 Other <br />>gof.vells f Soil �oroomUS G Geolearilcal Tctbedngs <br />O Prlottiroring Webs) 9(s) <br />O Out-0fSerAce Well C Out-0fService Well Renewal C Cmss-Connectim Repair CC <br />c__i­._. n v„mn Renal D Raise Well Casing <br />Drilltng Method O D4ud Rotary r "Rotary ri Auger 7 Cable Tool ❑ Push Point r) Other <br />Wei <br />Proposed Well Oepth ft Extauation in diameter = Open 80dom G Gravel PaddGravel Size in d - <br />O Corwhictor Casing in diameter I CCndectorCasing OEplh n HATH <br />Well Casing Diameter _ in ThiCkrIMS/Gauge7ASTM Sched -Steel Plastic c Stainless Steel D - Other <br />Grout Seat Depth ft O Neal Cement (941b b39r5-70 gat wafer) 7 Sand Cement sack maf7 gaJv27erl <br />D Bentonite (20% sotlds) D Other <br />Grout Placement Method G Purrlped O Free Fall -3 Other 'u Retardant / Accelerator (name) <br />I <br />PEDexw_ installed By D DI'llier 3 PUMP Contactor ❑ Other <br />C Concrete Pedestal CDlmensidns Width ft Length nThick _ _ in -iChristy hoz 7 Store Plpe <br />PULP Sutlmersib eO Turbine :)Other-- HP Pump Set R Standing Water Level h <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DOME IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED UCErM IS <br />CURRENT AND ACTIVE WITH THE CAUFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />MIN M 2 I f0 AD NCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (2fl9) 953 7697 <br />S1cNcD yW.,xL T,.Lro r p o r a t e S e c r e t o r Uf <br />m <br />D <br />0 <br />D <br />N <br />��ENT <br />062018 <br />fk6OUN <br />A. Ty <br />&L— <br />EKD43.^s 4iatri9 <br />Dunt I Date <br />Involeet' I Wen ID# <br />V!_.1(PUtPPEiti LIIT <br />Z'd VZSCZ9960Z out sielp(] eouei/und etZ: L L 9L Lp, End <br />D A HENT U E LY <br />Application Accepted By <br />Grout Inspection By <br />ate <br />Cate , , <br />Employee IDA <br />ATeaMLIlPermit <br />WANER ReCBIVBd <br />Pump Inspection ey <br />Dale (�'-� i p t% I b �/ <br />C <br />L7 <br />Date <br />constructed Wen Depth R <br />Sat Boring Inspection By <br />COMMENTS <br />&L— <br />EKD43.^s 4iatri9 <br />Dunt I Date <br />Involeet' I Wen ID# <br />V!_.1(PUtPPEiti LIIT <br />Z'd VZSCZ9960Z out sielp(] eouei/und etZ: L L 9L Lp, End <br />