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066 "N W l l SIOl 'Ol 'AON ;WI j paA1934y <br /> WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY EWROWE::TAL HEALTH DEAR TNenT 1868 EA3THAZEL70N AVQVC-STDCXTON CA 9E705-(209)4643420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATc ISSUED <br /> s <br /> JOD ADORL--S 9053 E ST Rt Mwy 4 cn-ymp StoCkton 95215 ';11 <br /> cRo3s STREETS Kaiser Rn API ja,�N-07 PARca.sgt.ANO u5E Appmanou a <br /> C.NER NAME Paul Sanuinetti 2.09-470-0672 <br /> Om,kAAcoREss 7677 E z, <br /> Hwy 4 CTYISTA-.z,, Stockton Cit c'5215 <br /> Cotrm;- loR Purviarce Drillers, Inc P„cuL209-A87-3554 <br /> f <br /> CormucTOR AOnRm P. O. 13 o X 64 — CITYlSTATF zp L i nc3 en r CA 95236 <br /> SUBCONTRACMR PHONE <br /> SUSCCNTRACToRAooREss _-____-- C.ITYISTATEILP _ <br /> LICEN]C _"l L D-W _Cther rJuwteER 377923 Ezp,RA7teer IY.TE 7/31 /17 <br /> GEOGRnpHCAJnrCRhinroN. Coordinates X Y Township_ Range Section_ ; <br /> SyrETatiO Use :DcrrIestic/Pnvate &iwgauonJAgncdAtmI 0Industnar VJ2ter CuattyMonilcnng _Soil Samp!inGlCharacmrira!Jon <br /> PuWc Water Sysiain <br /> IT d.1—m f—..Oyer. er em .— —' An ae — — r <br /> TYPE Qr WcRK _Nrw%f le! Replaxment'A'eil _Wet XNration)Mod imlian U O'hr. <br /> rAmitoring Wdl(s) O of wdS f:Soil Eonng(s) a o•bstnas _ Geotrchroml eoruinu: <br /> Out-C`-Scrvb-Well Out-Of-Serme Wei Rencpral i1 Cross-Conr.CCon R3,aIr ' <br /> NLW Pump _ Pwro Rtiplacemeni Pwnp Repair U Raise Wel Cssin <br /> WELL CONSIWIXTION <br /> Drilling I tclhed _rdud Anlary -AirRctay _:Auger -f Caale'rdcl ... Push Pdni _. Oftr <br /> Proposod Woll Cep;i It Ex wmt:on in d'crmala; -Open 8oltom C Gravel P26iQ'avel Sao in diatteterl <br /> Ccnductor Casing in diarreter I Conductor Casing Oepri tt r 1 <br /> Will Casing Clair.Lef_In TNcmess/GaugerAS TTA Scher -S:eel O Plastic E Stnirieas Steil ,_OLier <br /> Grout seal Capon fl ::Neat Cement J94 III hag 5-10 gal vm., C Sand Cernenl sack rr rn gai wam <br /> Bentonite(20%Bonds) - Othcr <br /> Grout Placement Metrod L Pumped -,Free Fitt Other _Retardant/Ac ceierator(name) <br /> PE57AL instalied By Z Driller m <br /> Pup Ccntacicr - Other -- <br /> rEO '_Can trete Pedestal'..Mmens ld rs:Wdth n Length nTn!cz In _Christy Boz a Stow Plpe <br /> UMp _5utIme1s•Llc&TurUine Other HP Pump Set fl Sttndirq VJoter Leuol rt <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATICN AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAGUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS- I ALSO GJZTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE 'WITti ALL <br /> WORK ENSATION LAV <br /> yS <br /> MINIM 4H CE NOTI;E REQUIRED FOR INSPECTIONS-PLEASE CALL(209)95:-7697 <br /> S,r,m all � Tri Corporate Secreta�,�€ <br /> IEDI i i r I <br /> ( ( I <br /> r 1 1 1 ki � i o 2015 <br /> TfI <br /> ENTAL HEAL=FN <br /> 1 I ' DIF RAT/SERVICES <br /> -4- flip <br /> ;q <br /> 13? <br /> A� R <br /> DEPARTMENT USV ONILY <br /> Appicf:on Acce;Ied By� Date IL Fjnployee lM r sQ <br /> Grout ln7DecOm B• <br /> '� Dam 7 PECIAL WBII Parrnit <br /> Pump lnsp-cs Dale G '' �.�� 7 WAIVER Received <br /> Soil Bodng Inspecton Bf pate Con3tructod Wsll Dopth It <br /> CONVENTS <br /> PE SG ' Recetwd Cltectl! ALnount Date Permit Invoice 0 VYef1 lot <br /> Codes Info I B Cash Remitted ServieoR uestA <br /> •L=717 ( fJ <br /> 9'd dZb:VO L060unf <br />