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IA;4hk Sc" �-1`I6 Oyr.� S9ll 'QN AdZl:S 9102 'Z 'daS aW11 panlaaa� <br />WELLIPUMP PERMIT <br />SAN JDAOu1N Couww Evmcr MENTAL HEALTH DEPARTMENT IE68 EASY HAZELTON AVENUE-.STOerrou CA 95205 - (20!9)469-3420 <br />NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />Joe ADDRESS 4726 N J a c kT o n e Rd cmr� �^ 9m-9-2-}.5 qS1 <br />CROSS STREET E Fairchild APNg:nq1-Q(& — —P—FL SZEa.36.­11. USE APPu.. # <br />OWNER NAME Vaccarezza Bros PRaNE209-482-4589 <br />OWNER ADDRESS 81 50 lV noncan R d crmsTA,,wap Linden CA 95236 <br />CONTRACTOR Purviance Drillers, Inca Pt"E 209-887-3554 <br />CONTRACTOR ADDRESS P. 0- Box 64 CrYISTAT-.MP Linden, Ck 9523 <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS Cn*dSTATFJAP <br />UcrosE I.i C-57 L: C-61 L D-109 Other NUMBER 377923 E,,, ,pp, DATE 7 / 31 / 1 7 <br />GEOGRAPHICAL INFORMAMON: Coordinates X Y Township_____— Range Section <br />INTENDED USE J Domest1cfPrivate ✓1Mlrrigatien/Agricultural 7 Industrial L• V4aterOualJty lAonil0ring G Soil Sampling)Charecteraalion <br />Public t•later System <br />Ifdtlfemntlrum O,unor, Vjw.r SY.Lri Name Goal= Me—a Pi.o. mwrber <br />TYPE Or WCRK New Well L Replacement Well U Wel NlerafonfMocKcation a caw <br />r- Monitorng Weil(s) #ot weiis r Soil Earing(s) a'I bail f• Geotechnical dafporlagr <br />n Out-Of-Servick-71011 I- Out -Cf -Service Well Renewal _ Cress -Connection Repair <br />Drifting Method _ Mud Rotary _ Air Rotary -Auger Cable Tobi _ Push Point u Other <br />Proposed Weli Depth tI Exravalion in diameter , Open Bottom 0 Gravel Pai:WGravel Sizs in diameter <br />u ConC. <br />duor Casing in diameter / Conductor Casing Depth (t <br />Wait Casing Dtamete; _, in Thfickmess/Gauge/ASTM Sched :7 Steel r Plastic = Sia:rtle'S Slee] -1 <br />Other <br />-- <br />G rout Seal Depth n I I Neat Cement (94 th bagz-iogaf water] D Sw,.d Cement sack mull gel outer <br />tT Bernonile(2 % sorrds) IT Other <br />Grout Placement Method CPumped Z,Free Fall C2 Other Relafdant/Accelerator (name) <br />!PEDESTAL Installed By r:, Driller D Pump Contractor u Other <br />L: Concrete Pedestal LDtmensions: Width ft Length tt"nick in L - Christy Boz I 1 Stove Pipe <br />IPUMP :1 SUbmersibJe.-Wurbine U Other HP _ _ Pump Set A Standing Waterlevel fl <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATICNS- I ALSO CERTIFY THAT MY REQUIRED IJCENSE IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL 1 <br />NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 53-7697 <br />T, Corporate Secret�,y,-5-1/(� <br />INA D PARTNiENT U E #ONLY <br />ApplicatfanAccepted Date l� <br />Grout Inspection By Date <br />Pump lnspectien 87 Date <br />sniff Baring Inspection By _ Date <br />COMMENTS <br />I� <br />CZ IL, <br />iD <br />• _, r_ �n_L71-1 <br />Area Employee iO*9mlL • — <br />El SPECIAL Weil Permit <br />WAivER Received <br />Constructed Well Depth <br />rr- ,t: rtecelvea t:necm Amount PermiU <br />Codes fnfn RV clah a.,. 1-1 Date „-_,-_ er•-�„ Invoice# well ID# <br />ob <br />13-05 <br />4ac OX-1 <br />/}•O�, / `✓ <br />euCn2 <br />0 L'd �ZSU9960Z <br />WELL YUVP P V MIT <br />out s.lejp.lQ eoueimnd <br />e/ 6:Z 6 ZO EOad' <br />