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1 <br />I WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN-KEFUNDABLE PERMIT t:ALL (ZUU) y53-11JUI FOR INSPECTIONS tAVIKtS I YEAR FROM UATE ISSUED <br />JOB ADDRESS 3310 N Murray Rd CITY/ZIPLinden, CA <br />CROSS STREET St Rt 26 Hy APN 10509020 <br />OWNER NAME Avansino, Raymond & Marilyn TR <br />OWNER ADDRESS 16820 E Comstock Rd <br />CONTRACTOR Purviance Drillers, Inc <br />CONTRACTOR ADDRESS PO Box 64 <br />SUBCONTRACTOR n/ a <br />SUBCONTRACTOR ADDRESS <br />LICENSE rX C-57 ❑ C-61 ❑ D-09 ❑ Other <br />PARCEL SIZE LAND USE APPLICATION # <br />PHON�09-481 -0597 <br />CITY/STATE/ZIPLinden, CA 95236 <br />CITYISTATE/ZIP <br />CITY/STATE/ZIP <br />PHONE 209-887-3554 <br />Linden, CA 95236 <br />PHONE <br />NUMBER 377923 EXPIRATION DATE 7 31 2 <br />DOMESTIC WELL SAMPLING: - General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE Domestic/Private X Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Ch60a�t Ration <br />Public Water System 't 1 <br />If different from Owner: Water System Name Contact Name or Phone <br />TYPE OF WORK )( New Well 0 Replacement Well ❑ Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings ❑ Geotechnicalf <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection RepdfiTiN,lO <br />❑ New Pum 11 Pump Replacement El Pump Repair ❑ Raise Well CasingFNVIRCIUIN COU <br />WELL CONSTRUCTION OEpIlv AL <br />ARTIyENT <br />Drilling Method Rf Mud Rotary - Air Rotary ❑ Auger I Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth ,/So ft Excavation 19 /2- in diameter ffi Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br />❑ ConductoLCasing WA in diameter / Conductor Casing Depth ft <br />Well Casing Diameter/2!! in Thickness/Gauge/ASTM Sched •ZSD 9 Steel C Plastic J Stainless Steel ❑ Other <br />Grout Seal Depth 2.44 ft ❑ Neat Cement (94 lb bag/5 10 gal water) If Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) ❑ Other <br />Grout Placement Method % Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />DEDESTAL Installed By 1( Driller ❑ Pump Contractor ❑ Other <br />r Concrete Pedestal ❑Dimensions: Width _!r gAUnchngth ft Thick <br />n Christy Box ❑ Stove Pipe <br />PUMP ❑ Submersible[] Turbine ❑ Other HP Pump Set ft Standing Water Level ft <br />Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the following items: GPS <br />Coordinates, property lines, adjoining properties, water bodies or courses, drainage pattern, roads, existing wells, structures, <br />potential sources of contamination, sewers or private disposal systems. Include distance from two property lines. For Domestic, <br />Agriculture, Industrial well, provide location of any water wells or surface water within 200' radius of proposed well. <br />NI ININII NI24110t 12 ll)i kNCE 1i)"H I." RE01 IRED 1700 1� <br />DEPARTMENT USE ONLY <br />Application Accepted By J i."'Date I v Area Y Employee ID# / / <br />Grout Inspection By y Date C SPECIAL Well Permit <br />Pump Inspection By Date ❑ WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS W7 Sr'j f r'}r9 L[IJ✓11 I< fe!i <br />rn <br />4 <br />m <br />D <br />v <br />v <br />m <br />m <br />.rn <br />PE I SC Received (`Check#J Amount Date <br />Codes Info B Remitted <br />Permit/ Invoice # Well ID# <br />rvice Request # <br />EHD043-06 10/25/2021 Page I of 2 Well / Pump Permit <br />