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6EC� '`N MG0 :01 6102 '9Z 'gaj raid paAl ;�;� <br /> WELLUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1888 EAST HAMLTON AVeME-STOCKTON CA 95265-(209)6683420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEARFROM DATE ISSUED <br /> JOB ADD R ss R Hwy c,,ZIP Stockton, CA ;m <br /> Boggiano Rdg <br /> CROSS STREET APN PARCEL SIZE -5 LAND USE APPLICATION R oA <br /> OWNER NAME Lawrence Sambado PKDN, 09-931 -2568 <br /> POBox 461 '7J Linden CA 95236 <br /> OWNeR ADDRESS O 1 { CITY/STATFlIJP / <br /> CONTRACTOR Purviancd Drillers , Inc pRoNE 209-887-3554 <br /> CONTRACTOR ADDRESS P O B o x 64 CnY/STATEIZ)P Linden,C a 95236 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CRY/STATEfZT <br /> LICENSE LX`G-57 D C-61 D D-09 a Other NUMaER 377923 ExPiRATIoN DATE 7/31/19 <br /> D6MEsnc VVELL SAstPLrNG:C General Mineral/Coh'form Bacteria(4391)C Dibromachloropropane(4392)--,Arsenic(4393) <br /> WFENOEO USE DomesficJPrivate Inigation/Agricultural 0 Industrial ❑Water Quality Monitoring O Sal Sampling/Characterization <br /> O Pudic Water System <br /> kdiNmrr.ham Owrar. Waler"t-14— Contact N."wPhem NUrtEer <br /> TYPE OF WORK D New Well ❑Replacement Welt D Well AlteralionfModdication 7 Other <br /> O Monitoring Wells) #aiweEs D Soo Boring(s) rormnngs 0 Geotechnical sdnnrings <br /> D Out-Of-Servic0 Out-Of-Service Well Renewal 3 Cross-Connection Repair <br /> r1 New Pum Pum Re lacement 'r7 Pump Repair 7 Raise Well Casing <br /> WELL CONSTRUCnav <br /> OrilllDg Method 0 Mud Rotary ❑Air Rotary C Auger ❑Cable Tool 0 Push Point ❑ Other <br /> Proposed Well Depth ft Excavation in diameter ❑Open Bottom C Gravel Pack/Gravel Size in diameter <br /> 3 Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_In ThicknesslGauge/ASTM Schell a Steel p Plastic U Stainless Steel U Other <br /> Grout Seal Depth ft U Neat Cement(94 lb bagrSlOgar water) ❑Sand Cement sack ndxg gal water <br /> U Bentonite(20%solids) 3 Other <br /> Grout Placement Method G Pumped Free Fall ❑Other ❑Retardant I Accelerator(name) <br /> PEDESTAL Installed By ❑Dnller U Pump Contractor D Other <br /> n Concrete Pedestal rlOimensions:VAdth ft Length It Thick in0 Christy Box G Stave Pipe <br /> PurvtP In Submersibl Turbine D Cther HP Pump S ft Standing Wader level- — fE <br /> I HEREBY CERTIFY THAT 1 E HAVPREPARED THIS APPLICATION AND THAT THE WORK WILE.. BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AMID ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT l AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> s,�N���UM 2 ,DVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953 7697 <br /> Ltu�S TiT.Corpor Sectary DATE 2/26/19 <br /> c <br /> I Ec MFT <br /> i F/VFO <br /> I I V, <br /> QNU�N C <br /> OOUN7 <br /> ti1FN ?' <br /> EPgRTrNT <br /> I � <br /> I <br /> i <br /> P TM ENT U E NLY <br /> Applical on Accepted By Dale'` Area' Employee ID* <br /> Inspection By '` Dale n;� 11SPECIAL Well Penult <br /> Pump Inspection By �1(�t4 k\OW L,��S� Dale ���u S /U(I iq ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Checim Amount Date Permit/ Inwioe# We111FNR <br /> C IrTfo B h Remitted Service R ueat# <br /> LOY <br /> EHDd3-06 "1/15 �U / I <br /> WELL/>Uhl➢PERMIT <br /> C'd tLSU9960Z OUB SJejji-l(] GOUoiAind nZ9:OL 6L 9Z qej <br />