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1 WELL/PUMP PERMIT <br />SAM JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-RFFHNnARI F PPORAIT t'`At 1 <br />-- I-- _ ___ . _.,. . —,., — ...—I,-,- L-^ru%c.O I I MAK t-KL)PA DATE ISSUED <br />JOBADDREss 20190 E Comstock Rd <br />CITYIZIP 1.i nden, CA 95236 <br />CROSS STREET H011 S t o n Rd APN 09131008 PARCEL SIZELAND USE APPLICATION # <br />OWNERNAME David Miller <br />PHONE2O9 986 2969 <br />OWNERADDRESS 20190 E Comstock RD CITY/STATE/ZIP Linden,CA 95236 <br />CONTRACTOR Purviance Drillers, Inc PHONE209-887-3554 <br />Box 64 Linden, CA 95236 <br />CONTRACTOR ADDRESS <br />CITYISTATE/ZIP <br />SUBCONTRACTOR n/a <br />PHONE <br />SUBCONTRACTOR ADDRESS CITY/STATEIZIP <br />LICENSE X -XC -57 ❑ G-61 ❑ D-09 ❑ Other NUMBER 377923 EXPIRATION DATE -7.13 1 / 2 3 <br />DOMESTIC WELL SAMPLING: �—' General MineraVColiform Bacteria (4391) i.Dibromochloropropane (4392) C Arsenic (4393) <br />INTENDED USE Nomestic/Private ❑ Irrigation/Agricultural ❑ Industrial 11❑ Water Quality monitoring Soil Sampling/Characterization <br />❑`Public Water System <br />If different from Owner. Water System Name Contact Name or Phone Number <br />TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings ❑ Geotechnical <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair V <br />-&/Pump <br />❑ New Pump Replacement FI.Pump Repair ❑ Raise Well Casing <br />WELLCONSTRUCTION AR 0 �—1 <br />S ,1 <br />��A Q <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary 0 Auger ❑ Cable Tool 0 Push Point ❑ Other SOOH <br />Proposed Well Depth ft Excavation in diameter 0 Open Bottom ❑ Gravel Pack/Grave IE$ <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft D �T <br />Well Casing <br />Diameter in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other TfiI <br />Grout Seal Depth It ❑ Neat Cement (94 lb bag/5-10 gal water) ❑ Sand Cement sackmiucl_ 7 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method 0 Pumped 0 Free Fall ❑ Other 0 Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller 0 Pump Contractor ❑ Other <br />❑ Concrete Pedestal ❑Dimensions: Width ft Length ft Thick <br />in ❑ Christy Box 0 Stove Pipe <br />PUMP Submersible❑ Turbine ❑ Other HP Pump Set It Stand Water Level d <br />.�....y � <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 />?l,;IW, .el.'_ -1'f'11 i;.LIli`XNCE• NoTI1`ER if?l ll r)"1rtlRl`tiPl:t 110_'-PI,FASECALL 12: <br />DEPARTMENT USE ONLY <br />Application Accepted By -�— �- Date_ = / .. ✓ Area ZI �'�% Employee ID#_rr r;11k <br />Grout Inspection By 4 A Date ❑ SPECIAL Well Permit <br />Pump Inspection By Date (q 2 2— ❑ WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />PE SC Received Check#! Amount <br />Codes Info Cash Remitted Dae <br />Permit! <br />ervice Re uest # <br />Invoice # Well ID# <br />mc <br />hhVU33-06 10:25/2021 Page I oft <br />1Vdl /Pump Permit <br />/3 X793 S`�_3 <br />