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i WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />S.lON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIKE5 7 YEAR FROM UATE ISSUE <br />JOBADDRESS 2IL&Qa Comstock Rd CITYIZIP Linden, CA 95236 <br />CROSS STREET Dema r t i n i Ln APN 09131012 PARCEL SIZE1 9 . 5 1 LAND USE APPLICATION # <br />OWNERNAME Dan Tejano PHONE 209 887 3296 <br />OWNERADDRESS P_0_ BOX 655 CITY/STATE/ZrPLinden,CA 95236 <br />CONTRACTOR Piy ry i A[7P T) r i 1 1 P r c r T n r-, PHONE2 0 9 887 3554 <br />CONTRACTOR ADDRESS P-0- BC)X 64 CITY/STATE/ZIP Linden , CA 95236 <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE CkC-57 ❑ C-61 ❑ D-09 ❑ Other <br />PHONE <br />CITY/STATE/ZIP <br />NUMBER 3 7 7 9 2 3 ExPIRATION DATE <br />DOMESTIC WELL SAMPLING: i- General Mineral/Coliform Bacteria (4391) = Dibromochloropropane (4392), 1 Arsenic (4393) <br />INTENDED USE ADomestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Owner. Water System Name Contact Name or Phone Number -PAA <br />TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other C <br />0 Monitoring Weli(s) # of wells ❑ Soil Boring(s) # of borings 0 Geotechnical # of borings <br />rl nllt_r)f QArvicP WAIT n out-nf-Service Well Renewal ❑ Cross -Connection Repair —SFR ? r <br />0 New Pump Pump Replacement ❑ Pump Repair ❑ Raise Well Casing — ` 'y 442-2 <br />WELL CONSTRUCTIONFNV/ 4 QU/N <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary 0 Auger 0 Cable Tool ❑ Push Point ❑ Other NEAT R0NM COUNT <br />Proposed Well Depth ft Excavation in diameter O Open Bottom ❑ Gravel Pack/Gravel Size I r <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth ft ❑ Neat Cement (94 /b bag/5-10 gat water) ❑ Sand Cement sack mW7 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method 0 Pumped 0 Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By 0 Driller 0 Pump Contractor ❑ Other <br />❑ Concrete Pedestal ❑Dimensions: Width ft Length ItThick <br />in ❑ Christy Box ❑ Stove Pipe <br />PUMPSubmersible❑ Turbine ❑ Other HP Pump Set-_ ft Standing Water Level I (n5 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 />DEPARTMENT USE ONLY <br />Application Accepted By .r^�_ 1 �- Date%✓ `/1.rvi <br />Grout Inspection By Date <br />Pump Inspection By L '� Date Z --7-- <br />Soil Boring Inspection By Date <br />COMMENTS <br />Area Employee ID# .. l _11k <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth <br />ft <br />Ln <br />4 <br />m <br />0 <br />0 <br />v <br />PE SC Received <br />Codes Info <br />Check#/ Amount Date Permit/ Invoice # Well ID# <br />Cash Remitted Service Request # <br />LI3R i 0 <br />f7 7 2.25-22 P60 0 <br />EHM3-06 IW512021 Page 1 of 2 We] I Pump Pemit <br />