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CONTRACTOR Purviance Drillers, Inc eHo„,209-887-3554 <br />CONTRACTOR Acmes, PO Box 64 cmisunalpLinden, CA 95236 <br />SUBCONTRACTORICONSULTANT PHONE <br />SUBCONTRACTOR/CONSULTANT ADDRESS Crry/STATEMp <br />Water SyMarn Name Contact Herne or Phone Number <br />*TENDED USE X Domestic/Private 0 Irrigation/Agricultural 0 industrial El Water Quality Monitoring 0 Soil Sampling/Characterization <br />0 Public Water System <br />If different horn Owner <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - &macron CA 95205 -8232 (209) 468.3420 <br />NON-REFUNDABLE PERMIT www.sigov.orgiehd EXPIRES 1 YEAR FROM DATE ISSUED 1246 Fine Rd JOB ADDRESS irazip Linden, CA 95236 c <br />CROSSRF_EP° pperopolis ApN 09304 076 ST <br />ommRNmn Dwight Michell <br />OWNER ADDRESS PO Box 1740 <br />PARCEL SIZE LAND USE APPLICATION 9 <br />PHONE <br />cayisTATEmuyalleySprings , CA 95236 <br />LICENSE k C-57 C-61 0 0-09 0 Other NUMMI 377923 Exp1rummlowm7/31/20 <br />BiumaPmtry: nOmea 2' CONTRACTOR Ii SUBCONTRACTOR1CONSULTANT <br />DOMESTIC WELL SAMSUNG: CI General MineraVColiform Bacteria (4391)0 Dibrornochloropropane (4392)c Arsenic (4393) <br />TYPE OF VVORN 0 New Well wenw Woe11 cReptacement Well <br />El Monitoring # of wells <br />Out-Of-SerAce Well <br />X New Pump u Pump Replacement <br />WELL CONSTRUCTION <br />Drilling Method C Mud Rotary LI Air Rotary U Auger <br />Proposed Well Depth ft Excavation <br />Well Casing <br />Grout Seal sack mbrI7 gal water <br />in diameter 0 Open Bottom 0 Gravel Pack/Gravel Size In diameter <br />0 Conductor Casing in diameter / Conductor Casing Depth II <br />Diameter ____ In Thickness/Gauge/ASTM Sched 0 Steel D Plastic 0 Stainless Steel Li Other <br />Depth ft 0 Neat Cement (94 /b bag/5-10 gel water) 0 Sand Cement <br />i: Bentonite (20% solids) 0 Other <br />I-I Well AJteration/Mocfrfication El Other <br /> <br />Soil Boring(s) a of borlropa Geolechnical a of Owings <br />Out-Of-Service Well Renewal it Cross-Connection Repair <br /> <br />0 Pump Repair 0 Raise Well Casing <br />El Cable Tool n Push Point 1.] Other <br />WELL/PUMP PERMIT <br />Grout Placement Method C Pumped CI Free Fall 0 Other 0 Retardant / Accelerator (name) <br />PROESTM. Installed By 0 Drifter C Pump Contractor C Other <br />0 Concrete Pedestal °Dimensions: Width ft Length <br /> <br />ft Thick <br /> <br />In 0 Christy Box 0 Stove Pipe <br />IM9de X Submersible: Turbine 0 Other HP 3 Pump Set IF/ It Standing Water Level ././4 ft <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED UCENSE IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE UCENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />7,4 40 R DVANCE NOTICE REQUIRED FOR INSPECT:ONS - PLEASE C.,ILL (2)3-707 <br />SIGNED fir) r tti TITLE Corporate Secretary "/ 21 /20 <br />II <br /> <br />2. <br />ns5 fta.) <br />DEPARTMENT USE ONLY <br /> <br />Application Accepted By D <br /> <br />Grout inspection By Data <br />e i/A47/Cv <br /> <br />Pump Inspection By c:f iNesS Lrt.: tXt-i 1 Date 1it9i7c1C <br /> <br />Soil Boring Inspection By Date <br />COMMENTS <br />Area 47/6-1 6/ Employee 109 sk <br />U SPECIAL Well Permit <br />ri WAIVER Received <br />Constructed Well Depth <br />ft <br />PE <br />Codes <br />SC <br />Info <br />Received <br />B. <br />Checkilft <br />icaeh <br />Amount <br />Remitted Date Permit/ <br />Service Request 0 Invoice # Well IDS <br />L/k0 0..i, d',, vis,____ ..4/s,2 z--2A.74) WCoo-ko-n-1 <br />... A if . . 67 Is-q3c) WELL /PUMP PERIIIT