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Com ---"- 17 L 5 > " ZS _") 6 <br />Well , /� Z <br />u Gt cll /Pump Pcrmit <br />I WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br />JOB ADDRESS 6373 Eight Mile RD <br />CITY/ZlpStockton, CA 95212 0 <br />CROSSSTREEEhantel Rd APN06303015 D <br />PARCEL SIZE 5 5 . 5 LAND USE APPLICATION # 04 <br />OWNER NAME Ori2one RAnch l�r 1 3 /� X <br />'�J: OfiyJl:E'. �•'P <br />PHONE 209 470 5757 <br />OWNER ADDRESS 5261 N Hwy 99 <br />CITY/STATEIZJP Stockton, CA 95212 <br />CONTRACTOR Purviance Drillers Inc <br />PO Box 64 PHONE209-887-3554 <br />CONTRACTORADDRESS Linden, CA 95236 <br />CITY/STATEJZIp <br />SUBCONTRACTOR n/a . <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />CITYISTATE/ZIP <br />LICENSE )C)r57 ❑ C-61 ❑ D-09 0 Other <br />EXPIRATION DATE , , 1 a 3 <br />DOMESTIC WELL SAMPLING: - General Mineral/Coliform Bacteria (4391) _ Dibromochloropropane (4392) - Arsenic (4393) <br />INTENDED USE ❑ Domestic /Private rrigation/Agricuftural ❑ Industrial 0 Water Quality Monitoring ❑ Soil Sampling/Characterization <br />❑ Public Water Syst <br />If different from Owner Water System Name <br />TYPE_ OF WORK ❑ New Well 0 Replacement Well ❑ Well Alteration/Modification <br />❑ Monitoring Well(s) # of wells ❑ Soil Borings) <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewa <br />Contact Name or Phone Number <br />❑ Other <br /># of borings ❑ Geotechnical <br /># of borings <br />1 0 Cross -Connection Repair <br />❑ Raise Well Casing_ <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary 0 Auger ❑ Cable Tool 0 Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel <br />0 Conductor Casingin diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched <br />Grout Seal Depth ft 0 Neat Cement (34 /b bag/5-10 gal Ovate❑ Steel El Plastic ❑Stainless Steel <br />11 Bentonite (20% solids) 0 Other % 0 Sand Cement <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other <br />❑ Retardant /Accelerator (name) <br />PEDESTAL Installed B ❑ D 'll <br />in <br />y n er ❑ Pump Contractor <br />❑ Concrete Pedestal ❑Dimensions: Width _ <br />❑ Christy Box ❑ Stove Pipe <br />❑ Other <br />ft Length ft Thick <br />❑ Otherj,* al(►�� <br />ga wate <br />PUMP ❑ Submereihiad Turbine ❑ Other HP ? i' y <br />Pump Set (nT ft Standing Water I I I <br />riot Flan 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 Date .7 Area �� Employee ID# <br />Grout Inspection By A Date <br />El SPECIAL Well Permit <br />Pump Inspection By •� � Date % I <br />Soil Boring Inspection By Date WAIVER Received <br />:OMMENTS Constructed Welt Depth ft <br />3� <br />