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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH <br /> 304 E WEBER AVE,THIRD FLOOR STOCKTON CA 95202 (2091468-34 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED O^' <br /> JOBADDRESS 26901 E. Hwy 4 ,3PN <br /> 6. CO.Y2IP Farmington, Ca �n <br /> PARCEL SIZC <br /> OWNERNAMEDaye Fleming ADDRESS P. O. Box 1389 <br /> CITYrtIP Sandy, OR 97055 PHONE 503-668-9220 <br /> CONTItAC1OR Purviance Drillers.Inc. wDDREsS P. O. Box 64 <br /> CITYaIP Linden, Ca 95236 PHONE 209-887-3554 C-52LICENSE#377923 EXPDATE7/03 <br /> GEOGRAPHICALINF'ORMATIOM COORDINATES X_ Y TOWNSHD'_ RANGE_SECTION <br /> TYPE OF WELL M NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑OTHER <br /> INSTALLATION: ❑WELLSYSTEMREPAIR ❑CROSS.CONNECTREPAM ❑VAPOREXTRACTIONWELL# <br /> ..a TYPEOFPUMP: W NEW 13 REPAIR N.P. 5 DEPTH PUMPSLr .FT. FIRSTWATERLEVEL <br /> ❑OUT-0F-SERVICE WELL ❑GEOTECHNICAL# ❑SOH.BORING ❑DESTRUCOON: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATH) <br /> ❑INDUSTRIAL Cl OPEN BOTTOM WELL EXCAVATION DIA 14 3 k6NDUCIOR CASING D4L_ <br /> ❑DOMESTIC PRIVATE ❑GRAVEL PACK/SIZE WELL CASNGTYPEsteel WELL CASING DIA S5/8 <br /> ❑PUBLICJMUNICB'AL ❑DRIVEN GROUT SEAL DEPOT 240 r SPECIPICATK)N .156 <br /> a� <br /> XM{IOUGATION/AG OTHERGROUTBRANDNAME cement <br /> ❑MONITORING GROUT SEAL PUMPED: XT YES ❑NO <br /> pan ❑CHRISTY BOX ❑STOVE PIPE CONCRETE PEDESTAL BY DIU LER: ❑YES ❑NO <br /> APPROXP.IATE WELLDEPOl 300 <br /> PROPOSFDCONSTRUCTION/DRILWGMETHOP. MUD ROTARY X AIR ROTARY—AUGER—CABLE—OTHER_ <br /> Y. I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE Wrnl SAN <br /> JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS.I ALSO CERTIFY THAT MY CST LICENSE IS CURRENT <br /> AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT l AM IN COMPLIANCE WTIH ALL WORKMAN'S <br /> COMPENSATION LAWS. <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> I sten/A'i,(T��-�-1 s.l�- F-"�=L_ Tm,E Corporate SeczetarY DaTEB/6/01 <br /> L <br /> L <br /> DEPARTMENTUSEONLY <br /> Application Aaxpmd By <br /> - MPmll <br /> r <br /> Grout mapecuon BY A{n �Dnm 7L/1 /Pomo mspecled By Dam <br /> Dwtroctlm mspec6on�dX Bp,'I� I� D.m /, <br /> r COMMENTS: 1141 1P M1M � �i l�l�J/ K�9 S 4.C Ca�N".( <br /> PE SC AMOUNT RECEIVED DALE PERMIT/SERVK-E REQUEST# WVOK.E# WELL HIk <br /> CODES 1 INTO REMITTED CASH BY <br /> � � G1 <br />