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1. WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />IVUIV-MtFUNUABLE PERMIT GALL Z09 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />Joe ADDRESS 5136 E Ashley Ln CITY/ZIP Stockton,CA 95212 <br />CROSS STREET N Ruff Ave APN 08510401 PARCEL SIZE -89 LAND USE APPLICATION # <br />OWNER NAME Claude Stewart <br />OWNERADDRESS 5136 E Ashley Ln <br />CONTRACTOR Purviance Drillers, Inc <br />PO Box 64 <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR n/a <br />SUBCONTRACTOR ADDRESS <br />LICENSE XXC-57 ❑ C-61 ❑ D-09 ❑ Other <br />PHONE 209 662 0497 <br />CITYISTATE21P Stockton, CA 95212 <br />PHONE 209-887-3554 <br />CITY/STATE/ZIP Linden, CA 95236 <br />PHONE <br />CITY/STATE/ZIP <br />NUMBER 377923 ExPIRATION DATE <br />DOMESTIC WELL SAMPLING: C General Mineral/Coliform Bacteria (4391) [, Dibromochloropropene (4392) Arsenic (4393) <br />INTENDED USE XDomestic/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 w _ <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-Mervice Well Renewal ❑ Cross -Connection Repair <br />D New Pump V Pump Replacement ❑ Pump Repair ❑ Raise Well Casino <br /># of borings I` <br />. fiEe 2 S <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑ Other HEq�T R�Nrv7 "SUN <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size <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 It ❑ Neat Cement (94 /b bag/5-10 gal water) ❑ Sand Cement sack mlxl7 gal wate <br />❑ Bentonite (20% solids) D Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant /Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal []Dimensions: Width ft Length ft Thick <br />�in ❑ Christy Box ❑ Stove Pioe <br />PUMP Submersible❑ Turbine ❑ Other HP __I_ Pump Set ( It 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 />DEPARTMENT USE ONLY <br />Application Accepted By l Date d y �� Area �i Employee ID# F> ; I'Z ({ <br />Grout Inspection By Date ❑ SPECIAL Well Permit <br />Pump Inspection By ' &1L' , Date Z ` Z 2 ❑ WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />T <br />PE <br />Codes <br />SC Received <br />Info B <br />Check#/ Amount <br />Cash Remitted <br />Date <br />Permit/ Invoice # Well ID# <br />Service Request # <br />4'77 <br />2-25-'27 <br />VJP H3004-- <br />c.tww!-Ub IUU.SI2021 Page 1 oft Well lPumpPcrmit <br />