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ALL,/) Ct-? Act; W-% SS00 "N W1:11 91H 9l aag awil pan i a�a� <br />WELLIPUMP PERMIT <br />SAN JOADUIH COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1 B68 EAST HAZELTOX AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS E:XPIRE5 T TEAR FROM DATE 155Uty <br />JOBACORFSS 2547 N JackTone RDf ctT,r� Stockton 95215 <br />CROSS S TREET H w V 26 APN 10-3 l PARCEL SRE ; -> LANG usE APPI."T10N * <br />OwNERNardE Milton Rangel PHONE 209-598-0055 <br />OWNER ADDRESS2 5 4 7 N JackTone RD c,T,,,STAT�PS t o c k t o n Ch 95215 <br />CONTRACTOR <br />Purviance Drillers, Inc. PHONE 209-687-3554 <br />CONTRACTOR ADORFDS P. O • Rox 64CTnISTATFrrm Linden, CA 9 5 23 <br />ADDRESS <br />u 0-57 u C-61 if "9 Lj <br />PHONE <br />_ CrTY/STA7FIZP <br />WFMER 377923 E.,,... DA <br />7/31/17 <br />I.,rneuln�.w• C.nnrdlnates x Y Township— Range Secoon <br />wrENDEn.UsE DomesticlPrivate 7! InigationlAgticultural L' Industrial u Water Quality Monimring r Soil Sampling/Characterization <br />Public Water Syslem Ie,e <br />Ntl1lfererif—Ovmer. err ys em e e Gr r <br />TYPEOF WORK New Well . Replacement Well !_ WelIAiteralronrMoclOpcaeon U Vmer <br />a al borvgs <br />r MofuWting Wetl(s1 Atry <br />of wells r. Sad 1t of ba s Boring(S) r- Geotechnical <br />-1 Out-Of-Servica Well r Out -OT -Service Well Renewal r Crow -Connection Repair <br />I New Pump s Pump Replacement r Pump Repair O Raise Well Casing _ <br />W ELLCONSTRUCTION <br />'Drilling Method u Mud Rotary _ Air Rotary ..I Auger Cable Tool J Push Point U Other <br />Proposed Well Depth fl Excavation in diameter U Open Bottom J Gravel PaeWGravel Size in diameter <br />u Conductor Casing in diameter I Conductor Casing Oeplh ft <br />Well Casing Diameter _ in ThidrnesslGaugeJASTM Schierl U Sleel Plastic ;= Stafniess Steel O Other <br />Grout Seal Depth ft C Neat Cement (941b bag/S10 gatwaler) - Sand Cement satin nzW7 gal water <br />Fl Bentonite (20% solids) 1'1 Other <br />Grout placement Method - Pumped -1 Free Fall - Other D Retardant lAccelerator (name) <br />PEDESTAL Installed By C Driller Pump Contractor -] Other <br />Concrete Pedestal OimensionsANWtti ft Length ff Thick In Ll Christy Box j Stove Pipe <br />PUNPSubmerslbieu Turbine L: 01her HP Pump Se[ It Standing Wafer Level ft <br />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- 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br />WORKEItsr_ r—`e ENSATIONLAWS, <br />PA�MEN <br />RECE�V � <br />,SE? 11 <br />sxsJOAQUI1 <br />Hot <br />OF' <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Sall Boring Inspecifon By <br />COMMENTS <br />NCE NOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL (209),M3-7697 <br />r/ujcc pe <br />TrtLE Corporate SecretaXy, w <br />, <br />EHD 434G <br />4WIZ <br />9'd bL9£L9860Z <br />DEPARTMENT SE ONLY <br />Date L <br />Date <br />Date <br />Date <br />LEI VJED <br />26 2016 <br />YNTH <br />A. L `t Employee I A <br />SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth _ _ tt <br />DatePemtlu Invoice d Well IDa <br />Service Re uest q <br />�7-I6 52U07�i`d�i(a V��0034'�' <br />WELL /PUMP :IEF MIT <br />out sJelp(i eoueimnd dL 1:90 ZO 9Z add <br />