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I WELUPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />AIrlKI ate,-.....,._. _ <br />•"^��� «�+�� .ALL LU9 953-7597 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br />JOBADDRESS 9-1.22 Al ni nP Rd CrrY/ZIPStor-ktnn' C'A 95212 <br />CROSS STREET �13}fi APN 11 R 4 n -� n 2 2 PARCEL SIZO _ 1 5 LAND USE APPLICATION # <br />OWNER NAME F R C Cnl ari n Rnl ari PHONE 209 607 1 078 <br />OWNERADDRESS 9-1 22 Alpine Rd CITY/STATEIZIP gtC)rkInn fGA 9521 2 <br />CONTRACTOR Purviance Drillers Inc PHONE 209 887 3554 <br />CONTRACTOR ADDRESS p n gr X 64 CITY/STATE1zIP Linden, CA 95236 <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE CkC-57 ❑ C-61 ❑ D-09 ❑ Other <br />PHONE <br />CIY/STATEMP <br />NUMBER 377923 EXPIRATION DATE 7/ 31 / 2 3 <br />•VcLLQAMt I-iNti: L ueneral mineral/Coliform Bacteria (4391) - Dibromochloropropane (4392) �-- Arsenic (4393) <br />INTENDED USE Public <br />atter System <br />❑ IrrigatioNAgricuttural ❑Industrial 0 Water Quality Monitoring ❑ Soil Sampling/Characterization <br />❑ PubficWaterSystem <br />If different from Owner. Water System Name Contact Name or Phone Number <br />TYPE Or WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br />0 Monitoring Wells) # of wells ❑ Soil Boring(s) # of borings ❑Geotechnical of borings <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />New Pump ❑ Pumn Renlacamc+nf HYD,.— Dente:, r <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter 11Open Bottom 0 Gravel Pack/Gravel <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel 0 Plastic ❑ Stainless Steel <br />Grout Seal Depth ft 0 Neat Cement (94 lb bag45-10 gal water) E Sand Cement <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retard t /A <br />an cceierator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />0 Concrete Pedestal ❑Dimensions: Width ft Length ft Thick <br />in ❑ Christy Box ❑ Stove Pipe <br />L <br />I FNM <br />❑ Other H D�pq <br />_ sack mix/7 gal water <br />rum" XSubmersible❑ Turbine ❑ Other HP c9— Pump Set q 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 />DEPARTMENT USE ONLY <br />i <br />Application Accepted By l r— <br />Grout inspection By _ <br />Pump Inspection By , L <br />Soil Boring Inspection By 5 <br />COMMENTS <br />PE <br />Codes <br />SC Received <br />Info <br />Check#t <br />Cash <br />Amount <br />Remittec <br />Date �L / �2 Area y (r (� <br />Employee ID# I- <br />`� ; I ` /( <br />Date ❑ SPECIAL Well Permit <br />Date ❑ WAIVER Received <br />Date Constructed Well Depth ft <br />Permit/ I - <br />oe ... Invoice # <br />Well ID# <br />EHDO43-06 10/252o2 i <br />V Pig c 1 or? <br />tVctt !Pump Prnnit <br />m <br />D <br />C3 <br />X <br />m <br />VNT <br />ED <br />20�2 <br />lCq NTY <br />ANT <br />