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• r 1 <br />I WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />PERMIT GALL (2U91 953-7597 FOR INSPECTIONS EAPIKt5 7 YEAR FROM DATE ISSUED <br />JOBADDRESS 11682 .Sun RCI CITYIZIP .Si-arktr)n � CA 9521 5 <br />GROSS STREET Beecher RD APN 1 0317022 PARCEL SIZE . rJ LAND USE APPLICATION # <br />OWNERNAME Bc)b Gliadacinc)1 o PHONE 2 9 483 4158 <br />OWNERADDRESS 11682 Sun RD CITY/STATEI21PGi-nrkf-nn'rA-9521 5 <br />CONTRACTOR Purviance Dril]ers., Inc PHONE209 R$7-355 <br />CONTRACTOR ADDRESS P. O. BOX 64-- CITYISTATEIZIPT. i n d e -n f rA CI5 2 3 6 <br />ADDRESS <br />LICENSE Xi C-57 ❑ C-61 0 D-09 ❑ Other <br />PHONE <br />CrrY/STATE/ZIP <br />NUMBER '37792 EXPIRATION DATE <br />DOMESTIC WELL SAMPLING: 0 General Mineral/Coliform Bacteria (4391) L Dibromochioropropane (4392) ' Arsenic (4393) <br />INTENDED USE )(DomesticIPrivate ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br />❑ Public Water System - <br />Ir dderent from Owner Water System Name <br />Contact Name or Phone <br />TYPE OF WORK ❑ New Well ❑ Replacement Well 0 Well Alteration/Modification ❑ Other ' A C 1. i?�1 e- <br />❑ Monitoring Well(s) # of wells 0 Soil Boring(s) # of borings 0 Geotechnical # of b;dhggsG�— <br />0 Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair AN 12 2022 <br />❑ New Pump ❑ Pump Replacement Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION ENS V1R AQUI N COUN <br />Drilling Method ❑ Mud Rotary 0 Air Rotary 0 Auger ❑ Cable Tool 0 Push Point 173 Other HEAL. NMENTA <br />Proposed Well Depth ft Excavation in diameter 0 Open Bottom 0 Gravel Pack/Gravel Size mete <br />❑ Conductor Casing in diameter / Conductor Casing Depth It <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel 0 Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth ft 0 Neat Cement (941b bag15-10 gal water) ❑ Sand Cement sack mnrR gal wate <br />0 Bentonite (20% solids) 0 Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other 0 Retardant / Accelerator (name) <br />PEDESTAL Installed By 0 Driller D Pump Contractor ❑ Other <br />❑ Concrete Pedestal ❑Dimensions: Width ft Length It Thick <br />lin ❑ Christy Box ❑ Stove Pioe <br />PUMP INSubmersibie❑ Turbine 0 Other HPI I — Pump Set LW f4 ft Standing Water Level C d -(o It <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 />T� DEPARTMENT USE ONLY <br />Application Accepted By Date 1 1RAI"', Area '1 Employee ID# <br />Grout Inspection Byte 11SPECIAL Well Permit <br />, <br />Pump Inspection By Gi Ti Date 77177 Z ❑ WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />Ln <br />m <br />D <br />0 <br />D <br />m <br />PE <br />Codes <br />SC Received Check#/ Amount Date Permit/ invoice # Well ID# <br />Info B Cash Remitted Service Request <br />43$x' <br />o,o .5_. <br />»o43.06 tonsrzazl%J �, 4 13 7 ; T���� Well /Pump Permit <br />