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1 <br />4 <br />Wti "N WHLS:OI 8lH 'Ll 'daS omit paAl;);� <br />WELLIPUMP PERMIT <br />SAN JOADUIN COUNTY EKywiONMENTAL HEALTH DEPARTMENT 1866 EASTHAzELTON AvENuE-S70cKToN CA 95205 -1209)468-3420 <br />N -REFUNDABLE Pr=Fwr CALL (209) 953-7697 FOR INSPECTIONS tAPIKi 9 YEAR FROM DATE I5SUEE <br />ADDRESS 11830 <br />1830 N a/,� /� Carnz ll i n d e n CA 95236 <br />SS STREET [�Y%� rCl( APN J ✓ PARCt1S12Ervi.7�USEAPFUCATIDW;; <br />£R NAME Lawrence Samb do PHoN20c) 931-256R <br />ER AOMESS P. 0. B o x 4 61 1.Q -o 1.1 TUt�.y`{ C(TYISTATEMPL i n d e n CA 95216 <br />TRACTOR Purviance Drillers, Inc PHOFL 209-887-3554 <br />TRACTOR Acwsss PO Box 64 CITYISTATEIZIPL i n d e n, C A 95236 <br />CDWIRAC70R <br />)R ADDRESS <br />CS U G-61 3 D-09 U <br />PHONE <br />CrTT)STATE0P <br />NutaaER 3 7 1112- 3 ESPiRATION DATE 7/31/19 <br />DONESTIO NfetLSAmPutfa: D General fAneral(Ccliform Bacteria (4391) - Dibromochloropropane (4392) D Arsenic (4393) <br />INTerro>=o USE O Comestic/Private jilnigationfAgricultural C Industrial O WalerQuafity, hTonitoriig f7 Soil Sam plingfCharaclerisalion <br />C Public Water System <br />ltdil'i from Owner Waler System Name Comars!Jame cr Phone Number <br />TYPE Oc WDRK D Ner! VMI E Reptacernenl Well 0 Well AlteratiDrllMod'dication 7 Other <br />0MonitoringWellts) 9 cf%wlls CSoil Boring(s) aofbonres GGeolechnicai <br />❑ OVt-Of-Seruice'Aell C Out -Of -Service Well Rene%v l 7 Cross -Connection Repair <br />orborincy <br />Drttling tAethod O Mud Rotary 17 Air Ratary -1 Auger ❑ Cable Tool .7 Pu=h Point O Other <br />Proposed Well Depth It Excavation in diameter D Open Bottom E Gravel Pack(Gravel Size in diameter <br />0 Conductor Casing in diameter f Conductor Casing Depth fl <br />Well Casfng Dmmeler _ in ThicknessfGaugeJASTM Sched _ Steel EiPlastic C Stainless Steel 3 Other <br />Grout Seal Daplh P, D bleat Cement (94 th bary5.90ga1 water) 7 Sand Cement sack rnbtl7 gat %valer <br />D Bentonite (20% solids) 7 OtW <br />Grout Placement Method 0 Pumped 0 Free Fal :1 Other 7 Retardant I Accelerator (name) <br />PEDESTAL Installed By O Driller B Pump Contactor 0 Other <br />O Concrete Pedestal GDlmenslons: Width ft Length It Tladc in 3 Chrlstyl3ox 0 5tove Pipe <br />Pum ❑ Suhmersiblap�furbine P10ther HP _ _ Pump Set tt Standing Water Level ft <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 REGULATIONS. 1 ALSO CERTIFY THAT rhY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AEA IN COMPLIANCE WITH ALL <br />NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />Tr,Porporate Secretar&,, Q -17—/r <br />Ln <br />m <br />0 <br />A <br />m <br />N <br />NT U E O L <br />Appllcalion A¢epted By ` OAS�= <br />to Area-'" Employee LD#JC.L <br />Grout Inspeclion By _ Date 1 PEGIAL Well Permit <br />Pump Inspection By f NA Date 'I WAIVER Received <br />Soil boring Inspection By Date Constructed Well Depth ft <br />COMAENTS <br />EMD 43 -CS &01116 <br />Z'd <br />VZSCZ9960Z <br />T7 <br />4,aL /PDt:.P PER RUT <br />out Sa811iJQ eoua/und P_/ Z:0 9L Z daS <br />ti %% <br />I IWIN=������Zi��.��►fT1��iig!��ri= <br />..�.�■�� <br />Com■ <br />�■ <br />EMD 43 -CS &01116 <br />Z'd <br />VZSCZ9960Z <br />T7 <br />4,aL /PDt:.P PER RUT <br />out Sa811iJQ eoua/und P_/ Z:0 9L Z daS <br />