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F-1 <br />Z <br />W <br />g <br />L <br />0 <br />!Y <br />Z <br />HH "N NVIS: l EH '0Z'ga ;Wli fD;Aia�ad <br />WELL/PUMP PERMIT <br />SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTU ENT 1866 EAST HAZEL -MN AVHVUE- S7—KTON CA 95205 - (2091468.1420 <br />N-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS tAY1Kt=b T TEAR FRUL167A tt 1,yAU1--U <br />ADDRESS 27100 Flood RD arnrzinden rA 95236 <br />ss STREEr Fine ?d APN 7 �Q ;'O PAMrLSOE�LAtm 11SE APPLCA -p <br />IER <br />NA4n thony Gandolfo Q A a 4,1 '"1 r 9-662-1421 <br />rER Anomms . cf7YlsTATEI2B i n d e n C A 95 2 3 6 <br />,R„MR Purviance Drillers, Inc PNDNE 209-887-3554 <br />TRACTOR ADDRESS PO Bax 64 CITY/STATEIZP L i n d e n, CA 95236 <br />cDNTRACIDA ADDRESS Cn YISTATE)ZA <br />C-57 0 C-61 0 D-09 U Olher NUMest, 7� L � DZPiRAmo* DATE - -- <br />nnucgTncwFt i SAmpuNr o C General MineralfColiform Bacteria (4391) yr.. DitlrDmochlompropane 14392) : Arsenic (4393) <br />INTrNOrD Use ❑ Domeak/Private ¢ Irrigation/Agrlicultural C Industrial 0 Water Quality Monitoring 0 Soil Samplin9fCharacterfza5on <br />❑ Pub]ic Water System DoraeG Name orPtrorre NomDer <br />(rWermr fromO vier. Water System Name <br />TYPE OF WORK 0 NeW Well E Replacement Well C Well Al leratianiMoolricalion 0 Other <br />O Monitoring Welts) Vof wells C Sag Borings) "Idtortm, n Geotechnical oar oonngs <br />0 Out-OfSendce Well 0 Out -Of -Se. m Well Renewal 0 Cross -Connection Repair <br />n New Puma A Pump Replacement r_ Pump Repair 0 Raise Well Casing <br />Drilling Method 0 Mud Rotary C Air Rotary O Auger 0 Cable Tao] 0 Push PolM ❑ Olh� <br />Proposed Well Depth N Excavation In diameter ❑ Open Sottcm C Gravel PacklGra%-A Size in diameter <br />❑ ConducberCasing in diameter f Conductor Casing Depth 11 <br />Well Casing Diameter _ In 7Ndmess1Gauge(ASTM Sched 7 Steel 0 Plastic 0 Sta niers Steel 0 Other <br />Grout Seal Depth ft ❑ Neat Cement (94 lb bag/SiOgal vrafer) c Sand Cement sack attI7 gal water <br />u Bentonite (20% solids) 0 01her <br />Grout Placement Method 0 Pumped 0 Free Fail C Otho G Retardant I Accelerator (name) <br />PEDESTAL Installed By ❑ Ddler O Pti np Contractor ❑ Other <br />❑ ConcretePedestai ❑Dimensions: Width it Length ft7hirk in it Christy Boz n Stove Plea <br />PUMP joSubmersible0 Turbine 0 Other HP� PUmO Set R Standing Water Level 'O R <br />1 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 NAY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE UCENSE BOARD AND THAT I AM IN COMPUANCE WITH ALL <br />MINI 2 R VANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209) <br />SIGNED corporate Secretary,,_. <br />Applicztidn Accepted By <br />If <br />J Groul Inspection By <br />L <br />Pump Inspection By <br />Sal Boring Inspection By <br />COMMENTS <br />j!/RTMENT USE LY <br />Date <br />Date <br />Date <br />Date <br />Area! q Employee I <br />17 SPECIAL Well Permit <br />Ci WAIVER Received <br />Constructed Well Depth <br />Miff <br />® ..: <br />C'd tLgEZ9960Z <br />ft <br />WELL IFUW PERWT <br />rn <br />n <br />A <br />01.11 SJaIIUQ eOUeiAlnd ept,: L L 8 L OZ qed <br />