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titi 'IN AVtiti: ll O [06 'l0 '100 awil pani ;3;� <br /> WELL/PUMP PERMIT <br /> SAN JOAQDW COLNTYENVIRONMENTAL HEAtnt DEPAwmwr r 1668EASTRA—TONAVENUE-STocrtToa CA 95205-(2D9)4583020 <br /> NON-REFUNDABLE PERnT CALL 209 953-7687 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joe ADDRESS Crriy. <br /> Lioss STREET APN V 2 23S2ED <br /> e <br /> x <br /> OWNER NAraE PHONE '" <br /> OWNER ADDRESS CrrYlSmtFJLr <br /> CCVMACTOR PurvianC Grillers , Inc pHA 209—�8r/8�7f-35—x54 <br /> CONTRAC'mR AnDness P O B o x 6 4 CMISr„EOPL i n d e n , CA 95236 <br /> SUHCON' AOR PHONE <br /> �SUSC DN7RAC7OR ADDRESS. CrtV/STA7El7JP <br /> LicEXME C-S7 u G61 ❑II-n9 a Otter NuluaEx 377923 ExPIRA-11ON DA1a 7/31/ 9 <br /> 1)0?-MsncMlle-_SAMPLWC:';Genera(NBrierauCoftforrn Bacteria(4391)—�Oibromachbmpmpane(4392)=Arsenic(4393) <br /> 1N1F7iIDED USE s oornasticiprnale F IrrigatiionmgriculMal G Industrial G Water Quality Monitoring G so]samprarglCharacteri�. <br /> C Public Water System <br /> trdiRereN hom Owner. WaterSystem rine Cwam Nine or 1`41011.Namw <br /> TVPEOPWORtr O Nea Wei C Replacement Well G WeffAleraGoNModific*6on O Other �VFD <br /> 0 Monitoring Well(s1 gafavells C Soil Boring(s) =arborinw p,•,ea��ical c <br /> D Out-Of-Service VMI C Out-QfServiM Weil Rena21 -3Cross-COnnecgDh RgpaY <br /> '3 New Pump q Purup Replacement G PUMP Re air -3 RalseWell Casing <br /> 20'� <br /> wF„CONSTRUCnOri OA <br /> 1Drilling McMad D Mud Rotary r..Air Rotary 7 Auger ❑Cable Tool .0 Push Point n Other ENV( QVi o1N7Y <br /> PraPOsed Well Depth it ExcwaUon in diameter G Open BOVOM C Gravel PacWGravet Sae r� TqL r 1 <br /> D Canductor Casing in durmeter, ! Conductor Casing Depth a TMEAIT <br /> Well CaaSing Cizmeter_in Thidaress/GaugelASTIVI Srhed -Steel D Plaslic C Stain!ess Steel 7 Gillet <br /> Grout Seat ff <br /> Depth ft D Neat Cement(94 fb DagrS70 ger lvateq 0 Sand Cement Sack mall gat Ureter <br /> e Bentonite(20°.6 solds) 7 Other <br /> GroutPlacaroentMethOd G Pumped ❑Free Fall :1 Older :3 RelardantfAceeleralor(name <br /> PeOESTAL installed By D Driller D Pump Contractor G Other <br /> n Concrete Pedestal CDlmerrslOns.V14d1h ft Length ft 7Tr ck In -)Christy Boz 0 StDve Plpe <br /> PUA,,P SuDrnersilNeO Turbine 0 Other HPPump Set tl Standing Water Lev1`3 R <br /> I HEREBY CERTIFY THAT t HAVE PREPARED THIS APPLICATION AND THAT THE WORK MILLBE DONE W ACCORDANCE WrT"SAN <br /> JOAQUIN COUNTY CMINANCES,STATE LAWS. AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED Ut NS£is <br /> CURRENT AND ACTNE WITH THE CALIFORNIA COAITRACTORS STATE LICENSE HOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS ATiON LAWS. <br /> MINlIfO 24 H CE NOZICE REQUIRED FOR INSPECTIONS-PLEASE CALL(2091954-76p7 <br /> SIO Tr,,forporate SeCretaryq,E/p3i /8' <br /> l i i <br /> i <br /> r J , <br /> I I I I l i I <br /> I I I ( I t <br /> I I I II <br /> 1 i <br /> I i <br /> I I <br /> I <br /> I <br /> EP RTMENT UE Y <br /> Applir26on Accepted BY Det.joj Area Employee 100t7 <br /> Grout Inspection eyDate D SPECIAL Well PerMit <br /> PUMP InSpeCSonByIaa' liW 61Q4 Dale '�� [I WAIVER Received <br /> Soil Boring Inspection 6y Gate Cons sled Wel[Depth ft <br /> COMMENTS <br /> PE SC Received Chceldt/ Qrnount Date Permitl <br /> Co es_.. Info -- -.—B ... .--- Cash.. -- - -- shifted .. ervice 4rrest'K InvcFreWell Icw <br /> I <br /> EY.043-M e9rn6 <br /> Z-d tZSUH60Z out SaalluQ aoul=.IAind ev L L L 26 L£100 <br />