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LOOS "N AV66 : 01 61H '0A <br /> ` I WELUPUMP PERMIT <br /> f <br /> a SAN JOAUUIN COUNTY Ew1RommENTAL HEALTH DEPARTIUENT 186a EAST HAZELTON AVENUE-SVOCK70N CA 95205-(209)466-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JoeADDREss 20389 E Walnut Dr c,,Izp Linden, Ca m <br /> CROSS STREET Wall Rd APN 0 91 -31 0-2 2 ppgcEL sizE". n <br /> 6 LAND USE APPLICAT ON# p <br /> Eilers Ranch LLC 209-462-6713 <br /> OWNER NAME PHONE m <br /> OWNERADDRESS PO Box 1048 C"1S1rA1FIZIP Linden, CA 95236 <br /> CONTRACTOR Purviance Drillers , Inc PHONE 209-887-3554 <br /> CONTRACTOR ADDRESS P 013 o x 64 CITYISTATIJ=ZIP L i nde n, C a 95236 <br /> SUBCONTRACTOR PHOkE <br /> SUBCONTRACTOR ADDRESS CITY/STATEIZIP <br /> LICENSE LXC ST L"'I J D-C9 U Other NUNBER 377923 EXPIRATIDN DATE <br /> DOMEsmc WELL SAMPLING:C General Mineral ccuorm Bacteria(4391)C Dibrornochicropropane(4392)-1 Arsenic(4393) <br /> INTENoED LhF DomesdcfPrivate x1irrigationfAgriculturaJ D Industrial D Water Quality Monitoring D SOD Sampling/Chamcterization <br /> Public Water System <br /> Ifd1T'rentrrom Owner. Watersyslem Neme Conlad Noee or Phone Number //�� <br /> TYPE OF WORx 7 New Wel D Replacement Well ❑Wel A llerstlonlMDdifcation D Other :4�M <br /> J Monitoring V001(s) 9 of wells C Sod Boring(s) a°reorngs D Geotechnical a of barslgs <br /> C Out-OrService Well C.Out-Of-Service Well Renewal U Cross-Connection Repair 1/� <br /> NewPornp C Pump Replacement JrPump Repair D Raise Well Casm v <br /> W ELL CONS7RU C'nON <br /> Drilling Method C Mud Rotary D Air Rotary D Auger U Cable Tool D Push Point D Other G/ e� <br /> Proposed Well Depth H Excavation in diameter C Open Boflom O Gravel PacldGravel Size in <br /> Conductor Casingnd'®rneter I Conductor Casing Depth fl -�Eq�T�R �NCpU <br /> ZO/ <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schell U Steel O Plastic D Stainless Steel Ll Other yn <br /> Grout Seat Depth H 7 Neat Cement r94 lb bag'5-10 gal rrdeo a Sand Cement sack mbdTq47 gal water R)M <br /> D Bentonite(20Y solids) ❑Other FNT <br /> Grout Placement Method D Pumped ❑Free Fall D Other C Retardant I Accelerator(name) <br /> PEDESTAL Installed By D Driller D Pump Co71rar3or D Outer <br /> Concrete Pedestal DDWernions:Width It Length R Thick In D Christy Bolt O Stove Pipe <br /> PUMP XSubmersibleo Turbine D Other HP Pump S ft Standing Water Level H <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE LN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS,AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED ]LICENSE LS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION <br /> MINIM 24 NCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953 7697 <br /> SIGNED iLl�r; c� TiTLE C o r p o r e c t a r y DATE . �a 9 <br /> I <br /> VL <br /> I <br /> I <br /> I <br /> I I <br /> 8 <br /> F�A MENT USE CJNLY <br /> Application Accepted By DaiAla -�� <br /> EpleyE ID4`� <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection ByDate ` \ 7 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth R <br /> COMMENTS <br /> PE Sc Received Check#1 Amount Date Perrnit/ <br /> Invoice# We111D# <br /> C es Info Cash Remitted SerNceR .est <br /> 2.1 <br /> I <br /> I I <br /> EHD43-0e &➢1119 � �/J , / ,/ WELLrP UI/E PFAIRn <br /> Z•d tL9U2960Z oul saalll.lQ 9oua/und e0t:60 66 06 AeN <br />