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—���'wl 5c�►� it-a�-Ib D� StiSO "N AOS : 6 9[0Z 'Z6 '3aa amij paAiaaa� <br /> WEi_LIPUMP PERMIT Q <br /> -A• SAN JoAOLIN CODNTY ENVIRONMENTAL HEALTH DEPARTUENT 1868 EAsTHAZrLTON AVENUE-STorKTON CA 95205-I209)468.34z1� <br /> NON-REFUNDABLEPEP-Par CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEARrRCMDATE1SStr_D <br /> Vl <br /> Jos ADDRESS X851 E Milton Rd CiTY0,Linden CA 95236 m <br /> CROSS STREET N Fine RD APN 1q 3//04W PARCELS 5 D USE APPLICATION A g <br /> iOWNHRNAME 4m44f24 PVT.I-- PHON209-887-3519 I N <br /> ICwm.-R ADDRESS 22015- E Milton RD CITYs,7,TsmPL i n d e n CA 95236 <br /> CONTRACTOR <br /> Purviance 'Drillers, PHONE Inc. 209-687-3554 <br /> CONTRACTOR ADDRESS P. 0. SOX 64 CRYISTATEJLp Linden, C Y 952-3 <br /> SUBCONMCTOR PHONE <br /> SOBCDN TRACTOR ADDRESS Crn9STATEli9P <br /> LMENSE L C-57 _C-61 1:-0-09 Other NUMBER 377923 ExFmAnoN DATE 7/31 /17 <br /> I <br /> GEDWAPHICALINFORAIA7101'r Coordinates Y Township^Range Section_ <br /> I N1eNOED USE 'DomesliclPrivale -lnigaUon/Agricultural C lndustrial Wa:or Quality Monitoring `-Sod Sampling/Cheraderization <br /> Public Neater System <br /> iIFElrterero fiom Ownac r Saer+� anno a . .nc ar none maser <br /> v J¢Rr l car'Fen1 VM IAWl Aeeralionlilodifica4on '._Other <br /> Prnt yI,(5) _ i4 SOUBoring(s) sarcolnes Geoledmital =0t <br /> zxwgs <br /> -��• � T-OGY11 y Out-OfLNel'R�e�• I Cr -Connection Repair <br /> J New Pum =Pump Replacement r pump <br /> um Repair <br /> Z Raise Well Castro <br /> F ve expire Wit ut <br /> riiltng htetho _ ud Rotary _A r RotarCabley <br /> fir.e7 Aug Push Point 011ier <br /> " 0wr in e indiameter_ I <br /> _ Open Bottom _Gravel Pack/Gravel Size In diameter• <br /> b ���]� (�n C sinj(� in diameter / Conductor Casing Depth R I <br /> iY\q ellfi® Af &&W&T'd$rJted Steel =Plasgc Sta nless Steel I Otlter <br /> GroutSeai Depth 11 _-Neat Cement(94/b bagrS-10 gal cater) _ Sand Cement Sark mud?galrmler <br /> -Bentonite(20%soles) ,:Dlher <br /> ,Grout Placernenr-Method _Pumped _i Free Fag =Other ==Retardant 1 Accelerator(name) <br /> PEDESTAL Installed By =Driller 2 Pump Contactor _ Other <br /> _Concrete Pedestal.,Dimensions:Width R Lenglh R Thick in _Christy Box Stove Pipe <br /> POUP I SutmersideL;Yurb:ne .Other HP Pump Set CTIh Standing Ydeler Leve! it I PAYMENT <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN I REXENE p <br /> JOAQUIN COLXNTY DRDIMANCE% STATE LAWS,AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT PAY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE VIIITH THE CAUFORNLA CONTRACTORS STATE LICENSE BOARD AND THAT I ALL IN COMPLIANCE WITH ALLEC� w <br /> WORKS fAPENSATION LAWS. y `208 <br /> YIINI M 24 R A VANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 q Y/Q <br /> StcNt� TITLE Corporate Secretes !a-(lYl6 -I 4okfCO(!MY <br /> +.J fo4RA-4 lia <br /> I 1 i <br /> 'VED <br /> 1 I s <br /> 1 2016 <br /> I � + <br /> I I I I VICE-TN <br /> I <br /> I <br /> 1 II I 1 # 11 11 1,.,- <br /> W,ENTSE LY <br /> Application Accepted Date AnaEmcoyee ID" <br /> GrDut Inspection B! Date 1 PECI L Weli Permit <br /> Pump Inspection By Oale D WAIVER Received <br /> Sol Bmlrg Inspection By A al Constructed Wei Depth It <br /> COU.MENTS <br /> PESC Received heckff Amount Dace Per Invoices: well]De <br /> Codes Info B Cash RemittedI Service Request# <br /> I <br /> WALL JPUtP PERlt1T <br /> anaT2 /VXr/�G// <br /> Z•d t'L5£L8960Z oul saellljl]eouel/und dZ9:90 ZO ZZ Inf <br />