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98WIN AVD:11 L106 '8 'ASA ;W11 paAl ;);� <br /> U1IELUPLIMP PERMIT <br /> SANJolIpUIN COUNSY ENVIRONh1ENTAL HEALTH DEPARTMENT 1868 EASTHAZELTON AVENUC-STQCKTON CA95ZD5- <br /> NON-REFUNDABLE PERMIT CALL CALL 209)963-7697 FOR INSPECTIONS EXPIRES 9 YEAR FROM DATE ISSUED <br /> Joe ADDREsS 7740 E . R a t t o Rd C,-r-PSo k o n —CA 9 5 7 T2 n <br /> Cno,s�,E.,HIldreth <br /> A PN 0 8 6 4 7 0 3 PARCE4 snzE .a LA„p Use(1pn41DA27 DN# o <br /> OWNER NAME Royce Northcott �LLAJ '�oS1r('CI PHc?j772-467-2437 <br /> OWNER ADORE-590 Trenton WayCIYISTA-MZPSt OCkton, CA 9521 <br /> CoNtnAc7DR Purviance . rillers, Inc. 1 <br /> PHONE <br /> 209-887-355 <br /> CONTRACTOR ADDRESS p- o, �3ox 5 4 CITYISTATEMP Linden, CA 9523 <br /> SUBCONTRACTOR <br /> PriONE <br /> ISU6c0NTRACT0R ADDRESS CITYISTATEIZta <br /> LICENSE t C-61 ;:D-0.9Olhar 3 7 7 9 2 37/31 /17 <br /> NUMBER EVIRATION DATE <br /> Gr0QNAPHICALIW,oRAIATIOrJ: Coordinates X y <br /> TDwnship Range Section_ I <br /> INTENDED Uss =DomesticYPrivate IrrjgaUon/Agrfcullurai 1-Industria[ _Water QualityMoniloring Soil SamptinglCharaderizatFDn <br /> Public Water System <br /> If Qd(er2n'from Owner. �M ysrrni ane <br /> - aNaa me or nr unner <br /> TYPE OF WORK New We]I Replacement Wei ...Well NtetauDNllodlficalion -i Olher <br /> tdonitodng Vdell(s) :oF wels t Suit Borings) 'o0^s'os •on DOdngs <br /> Gectechn'rrat <br /> Out-OfService Well -Out-Cr-Service tAselF Renewal "Cross-Connection Repair <br /> _I <br /> New Nano PUm Re lacement ° Pum Re air =Raise Welt Casic <br /> WELL CONSTRtrCT1oN <br /> Drilling(Method ::Njud Rotary _Air Rotary ..Auger !Cable Tool Push Pcint _ Olher <br /> �Proposed Well Depth ,t Excavation in diameter Open Bottom =Gravel PaddGravel Size <br /> Canduin diarneterl <br /> dorCasing inc5arneter I Conductor Casing Depth R <br /> Well Casing Diameter_in 7•hldtnetaJGauq&AST$A Schad Steel O Plastic Stainless Steel 011ier <br /> Grout Seal Depth It ;Neat Cement(9416 bWS-10ga)wafer) =Sad Cement <br /> Bentonite(2046 solids) :Other �adr gal water <br /> Grcut Placement Method --Pumped : Free Fail =Other <br /> Retardant/Acceleralar(namej <br /> P(3JESTAL Installed By _Daller C:Pump Contractor J.— Other <br /> L Concrete Pedestal Dim ensiortss-VAdth R Length RTMdr n Christy Bo Stove Pips <br /> PUMP . Submersibles:Turbine ::OUrer HP <br /> Pump S ft Slanding Water Level R <br /> I HERBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE W17H SAN <br /> JOAQUIN COUNTY ORDINANCES, STA-r= LAWS,AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALJFORNIA CONTRACTORS STATE LICENSE BO(tR�AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> NOR PENSATrO WS- t 1 V <br /> 11RlNF FII(24 O R VANCZ NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> Slur ED TITLE Corporate Secretes 5/8/17 <br /> 1 i I <br /> { l I F <br /> 1 I i <br /> - <br /> I I fC=I I rM <br /> I I o <br /> I ii j I ca <br /> r <br /> l <br /> N EP RTMENT S ONLY <br /> Application Accepted By Date <br /> AreaLk— Emp oyae IDTM <br /> Grout Inspection By care L SPECIAL Well PetTnit <br /> Pump lnspecfion By 1V�f�Q Data 7� ] WAIVER ROCeived <br /> SOU Suffna Inspection By Hate Constructed VJeU Depth ft <br /> CONVAEN TS <br /> Pl= ! SG Received Check#! Amount Pennid <br /> Codes Info B sAI Remitted Date ServiDa Request# Invoice# Weil ID# <br /> OS° y0� W F0039N E5 <br /> air 1G <br /> ars'la c z It L� <br /> Z•d t'L90L9960Z oul s)ellla4 eouelAlnd d£0:90 ZO 90 oe4 <br />