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890 "N (00:88 8106 'l8 '2ny awi j paAI ;3;� <br /> WELUPUMP PERMIT i v <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTWENT 1868 EASTHAZELTON AVENUE-STOCXTON CA 96205-(2091468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209)953-7697 FDR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Jae ADDRESS 2547 N Jack oneR CrryjZ,P Stockton CA 95215 <br /> m <br /> CROSS sTREET Whitehouse Rd APN '' no <br /> I PARCEL SIZE LAND USE APPLICATION# ej <br /> ONMER NAME Milton Rangel PHoNE209-598-0055 <br /> OWNERABoRESs 2547..,N Jacktone RdCfMSTAIStockton CA 95215 H <br /> E/TJP <br /> CONTRACTOR Purviance Drillers Inc PH. 209-887-3554 <br /> CONTRACTOR ADDRESS PO Box 64 CITYISTATFJTIPL i a d e n, CA 95236 <br /> SUBCONTRACTOR <br /> PHONE <br /> SUBCONTRACTOR ADDRESS C TVISTATEIZjp <br /> uCENSF C-ST u C-61 D D-09 ❑Other NumBER 377923 ExPMAnON DATE 7/31/19 <br /> DOMESTIC WELL SAMPLING:❑General Minerawoliform Bacteria(4 391)C Dibromochlaropropane(4392)3 Arsenic(4393) <br /> INTENDED USE DomestlrlPrivate ❑tnigatioNggrieutural C Industrial C Water Ouali Montarin D Saif Sam In <br /> ty 9 p g/Charecieriraton <br /> 0 Public Water Syslem <br /> lldifrererrl Wm Owner. 'Mler5rslem Nemo Coraan Naule ur Phono Numtcr <br /> TYPEOP WORT( D New Well C Replacement Well D WdtAlleralion/Modification _Other <br /> - <br /> E Monitoring Well(s) of wells D Sol Baring(s) sorborings 7 Geotechnical so,;'.l, <br /> G Out-Of-Service Well D OW-Of-ServiceWell Renewal 0 CrOSS-Connection Repair <br /> O New Pum Pum R lacement r Pum Repair O Raise Well Casln <br /> WELL CONSTRUCTION <br /> Driatng Method 0 Mud Rotary n Air Rotary D Auger ❑Cable-Tool 7.Push Point ❑ Other <br /> Proposed Well Depth ft Excavation in d2meler u'Open Bottom C Gravel Pack(Gravef Size in diarreler <br /> C Conductor Casing in diameter / COndUCiOr Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schell G Sleet D Plastic C Stainless Steel D Other <br /> Grout Seal Depth ft O Neat Cement(94 lb baV&10 gal wafer) 0 Sand Cement <br /> sackmizl7 gal water <br /> ❑Bentrnile(20%solids) U Other <br /> Grout Placement Method C Pumped D Free Fat D Other D Retardant I Accelerator(name) <br /> PEDESTAL Installed By D Driller 0 Pump Contractor D Other <br /> ❑Concrete Pedestal❑Dimensions:Width fl Length It Thick in f:Christy Box 0 Stove Pipe <br /> PUMP 9 Submersibleo Turbine 2 Other HP Pump Se R Standing Water Level Ift <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE TH SAN <br /> JOAQUIN COUNTY ORDINANCES,STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM I <br /> WORKSN COMPLIANCE WITH ALL <br /> NSATION LA <br /> MINIM 24 HO A E NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNEDn orporate Secretarff, <br /> i <br /> CEIVEC <br /> Qr I <br /> UG 31 2018 <br /> ONMENTAL HEALTH <br /> RMIT/SERVICES <br /> E ARTMENT U EN�Y Application Accepted 13y Dale Arcs_!f l 1 Employee ID#V(It <br /> Groutinsper3lonBy Date i� SIAPECLWell Permit � w� <br /> Purnp In9pection By 71��d DateAI Z �_ I: WAIVER Received � t�O` �" <br /> Soil Boring Inspection By Date Constructed Well Depth <br /> COMMENTS O CIOWQQ�'w�� <br /> PE SC Reeetwed Check#/ Amount - �r- <br /> C Info Cash Itted Dade Service RePerml uest# Invoice# Well ID# ��0' <br /> EHD43-06 aal/ln <br /> WaL/PUMP PERNn <br /> 9'd VZSCZ9260Z out sielp4 eoueinund eI,Z 80 86 lE bny <br />