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6681 '°N WdS1 :8 L 1 0 6 Sl 'ln r @UJI J P a A I ;0 <br /> ' <br /> VVELL/PUMP PERMIT 2 <br /> SAN J0412M COUtI re ENVIRONMENTAL HEALTH DEPARTMENT 16611 EASTHAzELTON AVENUE•STOCKTOR CA 95205-(209146S.3420 <br /> NON-REFUNDABLE PERMIT CALL 209_)953-7697 FOR INSPECTIONs EXPIRES 1 YEARFROnt DATE ISSUED <br /> JOB ADDRE 7305 N Waverly Rda�,PLinden CA 95236 m <br /> b <br /> CROSS STREET APN d PARCEL S LAND Use APPUCATON A a <br /> 1OPAER NAME 3o Ce 1{attler O PHCNE209-768-4673 <br /> OTTNER ADDRESS 7305 N Waverly R d cnY/ST717E2JP Linden CA 95236 <br /> (CONTRACTOR Purviance Drillers, Inc. PHONE 209-887-3554 <br /> .CONTRACTOR ADDRESS P. 0. T30X 64 CITY/S+MTE/ZM Linden, CA 9523 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRrlCMR ADDRESS 07YISTATEr21P <br /> UcaNsE csr _C-61 :.:0-09 _other NumoER 3 7 7 9 2 3 Exp RATON DATE 7/31 /17 <br /> GEOGRAPKCALIR—MATDN: Coordinates X Y Township_ Range Section_ <br /> J_MER-num ADamestfuPrivale Irrigation/Agtimltuml _industriai :I Water Quality M(u1ilnring Soil Sam fuiglChardaeriMliOn <br /> Public Water System <br /> IrtlnercrN rnm Owrsr. -ger m ame n rine or ne vetoer <br /> TYPEOFV1om( _New tAWr Replacement well 1%W11Alteralfammodiricalion -i Other <br /> Morutoting Wel(eA m of wells ^Sal Borings) a of:adnp t Geolerhnical iorporirgs <br /> Out-0=SUFVa Wa11 -Out-O"ervioe Nell Rene�ra) :'1 Cross-Connection Repair <br /> =:NatvPump Pump Re l2czrnenl i:Pump Repair Raise Well Casinq <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary _Air Rotary -Auger L.Cable Tool _Push Point _ Other <br /> Proposed Well Depth R Excavationin diameter :_Open Bottom _Gravel Pack/Gravel Size in diameter <br /> Ccndutxor Casing In diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_do Th'rkness/GaugeIASTM Sched Steel -Plastic =Suunles-s Steel 2-Other <br /> Grout Sea] DePih ft `Neel cement(94/b bay5-10ga1 wate1) _Sand CenTenl �� gal�� <br /> Senlonrle(VrA solids) :'!Olher <br /> ter <br /> Grout Placement Method Pumped .-i Free Fall -Olher G Retardant/Accelerator(name) <br /> IPemm AL Installed By Driller ;Pump Contractor Dlher <br /> Concrete Pedesta3_Dimensions RAfdlh R Length 11TWCK n Christy Box Stove Pipe <br /> i <br /> P MP WSubmersibleu Turbine Other HP Pump Set R Standing Nraler Level ft , <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAOUIN COUNTY ORDINANCES, STATE MWS,AND RULES AND REGULATIONS- 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> WORK NSATATION LAWS- <br /> STAT <br /> CURRENT AND ACT IT <br /> WH THE CALIFORNIA CONTRACTORS E LICENSE BOARD AND THAT 1 AM IN COMPLIANCE Wrr-,q ALL <br /> MINIM 24 HOC! VA E NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-76!47 <br /> stcnED ' . x. Tm, Corporate Secretigy -7�; <br /> I <br /> L r9a <br /> N EX 43 if <br /> i <br /> F � <br /> I <br /> N <br /> O <br /> l d <br /> E MT AE <br /> ` rill <br /> 1 3 <br /> I t I a <br /> F <br /> EP RTMENT YSEONLY � �(� <br /> Application Accepted net, : (� eg'_' <br /> Area LH`1�I Ergpoyee IDg <br /> Grout Inspection By Date !!i SPECIAL Well Permit <br /> Pump Inspection 8y Dale ❑ WAIVER Received <br /> SGil Boring Inspection By Date Constructed Well Depth it <br /> CO NTS <br /> Co L t C.t F <br /> PE SC Receiv d CheddX Amount Permit/ <br /> Codes ^Info B Cash Remitted Date Service Re vestT Invoice# WelI ID# <br /> �r So to <br /> EHO a}ea <br /> WELL P.RL= <br /> Z'd VL9EL2260Z oul saelp(]eoueimnd d96 E0 L L 9 L Inf <br />