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' zS�Z '�N WdSZ l l L IOZ 'SZ 'd9S aW l j P;A I G );� <br />WELUPUMP PERMIT <br />SaN JoAouIN COUNTY ENVIROWAWTAL HEALTH DEPARTMENT 1868 EAST HAZELToN AVENUE - SrocKTON CA 95205 - (20 9) 463-3420 <br />NON -R M%- RMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />!JOB ADDREss22205 E Frailer -Rcf <br />/['r CrTylzh,jndi-n CA A59'36 <br />CROSS $TREEIC1elne ntsD ApN 065210�J� PARCEL$IZE v LAND USEAPPLICATIONAt_ <br />OWNER NANE= ►� Brett Lagori0 (Jdht" F1G z:�i f"Cr) PHONE 209-351-1220 <br />OWNER AMRE3S 18600 Tobacco Rd CITYISTATEMPL i n d e n CA 95236 <br />CONTRACTOR Purviance Drillers, Inc. pHD,,209-887-3554 <br />CONTRACTOR AODRE33 P. 0, Box 6 4 CINISTATHLP Linden, CA 95236 <br />SUBCONTRACTOR <br />I PHONE <br />.SUBCONTRAACTOR AMFtEsS CITYISTATEIZIP <br />LICENSE 1L: C.57 1_! C-61 !.. D-09 ;.! Other NUMBER 3-1=— 7 9 2— Exr!RAnoN DATE 7 L,� 1 9 <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Tcw,.noh;. oa....e <br />NTENOED USE ! Oomestiuprivate ZrrigatiaMAgriwLural - I Industrial Water quality Monitoring i:! Soil SarlplinglCharaderiration <br />Public Water System <br />Irdiffeml from Owner. WAfertrateM NAme a rtes or one <br />„ .00 ..�„ recyid,,cinern uvea - vvel AHLMaeONModIncation L. Otho <br />MoniloringWen(s)Cofwefs '1SonBorings) Sartonngs I GeWechnical Oufbcfts <br />Out -Of -Service Well : ! Out -Of -Service Well Renewal r! Cross -Connection Repan <br />Drilling Mothod U Mud Rotary .. Air -Rotary � Auger !.; CableTDol J Push Point 1.1 Other <br />Proposed Wall Depth ft Excavation in diameter a Open Bottom ❑Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter I Conductor Casing Depth R <br />Wen Casing Diameter_ in Thickness/GaugefASTM Schell G Steel U Plastic L Stainless Steel G Other <br />Grout Seal Depth n C Neat Ceneent (94 lb ba915.10 got wafer) L' Sand Cement sack rnbT7 gat wraler <br />_ Benlorite (20% sor!ds) U Other <br />Grout Placement Method a Pimped C Free Fan Other 1 Retardant/Accelerator (name) <br />PEDESTAL Installed By I ! Driller C Pump Contractor C 01her <br />I.! Concrete Pedestal 1 -Dimensions! Width it Length H That in Lf Christy BOX U Stove Pipe <br />Puh P I I Submersibi Turbine U Other HP Pump Se -5—'00 ft Standing Water Level H <br />I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WALL BE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS- 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPr p,^;C5 Y:tTH ALL <br />WORKERZNSAT1014 LA <br />MINIM I 24 H D NCE NOLTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SHED TITLEC O r p Secretary DATE 9/25/17 <br />/pP G�`Jw 1 <br />5 \1 e <br />�� r1 Accepted By <br />:? 1• P� Grout Inspecllon By <br />��\Fo" 9p 'f Ot Pump lnspechon By <br />N�ytl Sal Boring Inspection By <br />COMMENTS <br />J <br />DEPARTMENT USE ONLY <br />Date <br />Date <br />Dale <br />Area Employee ID# �'Un <br />D PECI.L Well Permit <br />17 WAIVFR Received <br />Constructed Well Depth _ it <br />I^� <br />iD <br />�o <br />a <br />H <br />u <br />� 5 20117 <br />NMENTAL HEALj11 <br />WITISERVICES <br />PE <br />Codes <br />SC Received <br />Info B <br />Ch9Ckil1 <br />Cash <br />Amount D Permit/ nvoice# WeRiDtt <br />Remitted Service R uestYr <br />3 r1 <br />aS <br /><<5�-- <br />? DIN <br />gnar,_ - - <br />NEIL fFVVP P-rRIAn <br />Z'd bZSCZ2960Z out s.Aajji.lQ eoutauund eVZ'. L L L 6 9Z deS <br />