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�OWIN Ad Wl � I OZ 'h l 'AON ;W l j P;A l; D;� <br />WELUPUMP PERMIT <br />SAN JOAOUrN CDLwTTY ENV1R0iWJ.E11TALHFALTH DEPARPIiENT lass EAST HAZELTCN AVENUE-STOCKTON CA 45205 - (219)4615-3420 <br />NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR lNS?ECTICNS EXPIRES 4 YEARFROM Da DEa <br />Joa ADDRESS " I CrTYMP _ m <br />( D <br />Lltoss STREET �1 3( �1 I t.V' �`� AP. / G � PARCELS¢F Larro UsE Aavucanox F <br />p n <br />OWAIER NAtlz ocL,,Ali 1;r`l// 1 CPHOCN=- ) <br />OWn'ER ADDRESS . I� 1i %til . CDrlSraTE" <br />CONTRACTOR Purviance Drillers, Inc PHOH=_ 2n9-887-3554 <br />CON7RRACTOR AODREMS PO Box 64 crrvlsTATfrLPL I n d e T1 , CA ° 5 2 3 6 <br />SUBCONTRADTOR PHONE <br />SUHCOAITRACTOR ADDREMS CMISTATE17W <br />(LICENSE R C-57 ❑ G81 ❑ 1)4-19 ❑ Other NUL,EER 377923 ETwRAToN DATE 7 / 31 / i 9 <br />Dcl?. r WE r SAWLMG_ ^ General I6linerallColifoirn HaaLP:ia (4391) ` D9tmmochiorap7opane (4392) -.-Arsenic: (4393) <br />tNTEIM D USE lbOemesliclPdwate C Intgalion(Agdcultural G Industrial r Wa[erOuafity Woniloring O Sal SampGngfCharactcri�tion <br />C Fub!izWater Sliatem <br />'.f?cTevilfrnrn Qwner. <br />Wier Syst—I\Rrre Cantzd rta= w Part Nurnner <br />TYPE Or WORK O Ne^u74ell C Replacement VYell a We; AtluacftrtAO[55�:a1:an C Other <br />n ,�1.onitoring W=_il(s) * o`%ve1Ls G Shc aadng(s) =°r e'd''3' G Geotechnical r- or to -?s <br />C. Cut-0fSerrice Wert C Out-0fSen4ic a Wel Renes+at 7 CrD6sJrenneeton Repair <br />O New Pum (5 Purnp Re IEcenent CC Ptrmp Repair 3 Raise Well Casing <br />WELL CDNSTRUCTioa7 <br />Drilling Method O Nud Ratary r Air Rotarl ] Auger C Cable Tool O Posh Pint C. Other ' <br />Proposed Well Depth ft Excavation in diameter = Open Bottom G Gravel PaddGraveal Siwe in d:meler <br />O Ccnduclor Casing in Ciarrmter i Conductor Casing Depth ft <br />Well Casing Diameter_ in ThldmesstGaugelASTMSched Slee) .3 Plastic C StahessSleel D OIher <br />Grout Seal Depth R 3 Neat Cement (94th bag'5-10 gal water) .2 Sand Cement Sack- rnxn gal„crier <br />C Bentcnii0 (20% solids) 3 Other <br />isroutPlacement Method 0 Pumped D Free Fag 7 Other 7, RelardanliAcce'erator(name)_ <br />P_-D7=9TAL Installed By D Driller 7 Pump Curinclor O Other <br />i C Concrete Pedestal CMmenslors.-W &D A LtnrqM, It Track in : Christy Box rJ StavePlpe <br />Pun v & Submel*,ible0 TuMirs 0 Other H? Pump Set fl Standing Whaler Leue1 1t <br />Z HEREBY CERTIFY THAT 1 HAVE PREPARED 7r11S AIPPUCATiON AND THAT THE WORK WILL 13E DONE IN ACCORDANCE W(TN Spit <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS. AND RULFS AND REGULATIONS. I ALSO CETMFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTT WfTH THE_ UFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AIA IN COMPLIANCE WITH ALL <br />WOR PENSATION LANtS- <br />MINI 26 H NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7657 <br />,,Corporate Secretar�A,E //- I JP <br />A HENT U -EO LY <br />Application Accepted By c Date <br />Grout Inspectim ey (,h, Oa,1e <br />Pump Inspection BY n1 \�UC� v c1� t'r"^°'e i -c <br />Soil acting Inspection By Cate <br />COMMENTS <br />Area Employee lD9 m4A- "I <br />PECIAL Well Permit <br />D VUAIvER Received <br />Constructed Well Depth ft <br />PE Sc Receivad ChetkPd Amount Permltf <br />C S- - Info - _ Cah . _. emitted Date.... Service Requests Invo[ce# Well IDS <br />■ <br />■ <br />■ <br />d8�:V0 2 L 6 6 A(:■� <br />a11D43C5 elnIC <br />L -d �ZSU9960Z <br />'l.�R-L rr'U::P P=t2aT <br />Out SJ811!-IQ eOueiA.Ind <br />