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L <br /> 8E '°N WdW� L[06 '06 'lnr IWI J paA I ;O;d <br /> VVELL/PLJDAP PERMIT <br /> • SAN JOAOUIN COUNYYEw RON&i-_NTAL HEALTH D EPARIM.'r 1888 EAST HALa.TGN AVENUE-STOMUCM CA 95205-(209)488-3420 <br /> NON-REFUNDABLE PERMIT CALL 209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOaAODREss 18867 Milton Rd C,n,Z.Linden CA 95236 <br /> m <br /> CROSS STftEET- -'._"`I)6tg41 Ril• APN--/0'5 1 0_9 PARCELSME -22<AKo USE APPLCAT[ON$ <br /> OWNERNAMEBill Gillick PHotN0.09-470-8591 m <br /> OWNERAODRESS19161 E Milton ,0 (,g, -v,,-- <br /> crrvisTAmmpLinden CA 95236 <br /> CONTRACTOR Purviance Drillers, Inc. PHOW 209-887-3554 <br /> CONTRACTOR ADORFSS P- C- RoX 64 C1Tr/STAT.-m;, T11nden, CA 9 5 23 <br /> SUBCONTRACTOR PHow I <br /> SUBCONTRACTOR Aop3t6Ss CIT(ISTATE17LP <br /> Lrc377923 7/31 /17 <br /> FXse �G57 �G61 is D-0.9 _Other NUNBER E1CPl.3AT70N DATE <br /> GEOGRAPKfCALINFORKIAYlON: Coordinates Y T—nShip_ Range Section_ <br /> 11UMMOUsE it DomOsI119privale 'Irrigation/Agricultural C Industrial 1 Water Quality Monitoring ^$Di!SamplinglCAaraderization <br /> Public Water System <br /> IrdiBamnl from OH r, er em e a a .ra or ana um r <br /> TYPE OF WORK _New Well L Replacement Well :,Welt Alteration/Modirrralion Dow <br /> MoNlcringWells) tt of wells I;SoilBodng(s) pa1bwdW I Geotechnical t otlmrllgs <br /> Out-OFService Well _,Out-Of-Service'A%fl Renewarl rl Cross-Connection Repair <br /> LNewPuptp 1A Pump Replacement L Pump Repair C Raise Wen Casing <br /> WELL CONSTRUCTION <br /> Orilling Method C Mud Rotary _ AirRotay _:Auger _Cabie_,ODI _Push Point _ Other <br /> Proposed Well Depot fl Excavation in diameter _Open Bcltom _Grarel Pack/Gravel Size in d ameter <br /> Conductor Casing in diameler / Conductor Casing Depth ft <br /> Vleil Casing Cianreler_in ThidmessiGaugelAST 4 Sched Steel Plastic Stainless St =Other <br /> Grout Seal Depth ft ^.Neat Cement(94/156ag/S-rOgal reater) _Sand Cement sack mbW gal%rater <br /> .-Bentonite(20--satids) -Other <br /> IG rout Plar-eme at Me thod a Pumped 17FreeFa1l =OUer C.Retardant IAccelerator(name) <br /> PecESTAL Installed By C Driller Pump Contractor , Other <br /> Concrete Pedestal_01mensiens:lR9dlh It Length ItThICu in :=Christy eox _Stove Pipe <br /> PULP Submersblet:Turbine :Other HP Pump Set ft Standing Wafer Level n <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE IMTH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT hlY REQUIRED LICENSE IS <br /> CURRE TME WITH 1HE CALIFORNIA CONTRACTORS STATE LICENSE: BOARD AND:THAT i AM IN COMPLIANCE WITH ALL <br /> W I'S COMP IpTipN LAWS- <br /> MINIM 24 gNCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)9S3-7697 <br /> s1ON TME Corporate SecretaliFy 7,,eo_jI <br /> ! M <br /> I � <br /> N <br /> E (Z o e. <br /> Ius`� e N <br /> Sh, <br /> v <br /> I <br /> ---71 <br /> 'Aff �A TMENT U E NLY <br /> APpticaliion Acceple d By Date <br /> t / A2a Employee I0� <br /> Grout inspection By Date WAIVESPECIAL—Well Permit <br /> rnw �D� <br /> PrpinspecUanBy Date ❑ R Received °V <br /> Sol Sorirtg nspeetion By Date Constructed Well Depth <br /> COMMENTS <br /> PE SC Reeeivea CheckN Amount Date PerTnit/ Invoiee9 welllldltq 'OgpON <br /> COdes Info B Cash Remitted Service upst COU <br /> 1ST a 3 FpgR ��1Y <br /> NELL/PUTAP P-pratT <br /> .%nom <br /> Z'd VL9£L8860Z out saellu4 eouein)nd d8b:150 L L 07 Inn <br />