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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (2D914f;R-'iG9n <br />— • - • --• vr�aa�G r GRIYII I MALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOBADDRESS 144-5 3 Vintage Rd <br />CITY21P Lodi , CA 95242 <br />CROSS STREET Ke t t l eman Ln APN 061 13242 PARCEL SIZE 2. 3 55 LAND USE APPLICATiON#/ <br />OWNER NAMEA n r7 i j<U t l i k PHONE 2 0 9 327 8222 <br />OWNER ADDRESS P.O. BoX 401 <br />CONTRACTOR Purviance Drillers, Inc <br />CONTRACTORADDRESSO BOX 64 <br />SUBCONTRACTOR n/ a <br />SUBCONTRACTOR ADDRESS <br />LICENSE XDAC57 ❑ C-61 ❑ D-09 ❑ Other <br />n,. <br />CmrISTATEIZIP Victor CA 95253 <br />PHONE209-887-3554 <br />CITY/STATEIZIP Linden, CA 95236 <br />PHONE <br />CITY/STATE21P <br />NUMBER 377923 EXPIRATION DATE 7% 3 1 - <br />••=r- mr—ulvu: veneral minerauGDlitorm Bacteria (4391)-.-, Dibromochlorapropane (4392) ,D Arsenic (4393) <br />INTENDED USE Domestic/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 <br />TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification <br />❑ Monitoring Well(s) # of wells ❑ Soil Borings) <br />❑ Out -Of -Service Well ❑ Out-Of•Service Well Renewa <br />❑ New Pum QLPump Replacement ❑ Pump Repair <br />❑ Other <br /># of borings ❑ Geotechnical <br />1 ❑ Cross -Connection Repair <br /># of borings <br />WELL CONSTRUCTION <br />Drilling Method ❑ Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool q Push Point ❑ Other / 9 <br />Proposed Wel! Depth ft Excavation in diameter ElOpen Bottom 11Gravel Pack/Gr ivel Size , <br />❑Conductor Casing in diameter / Conductor Casing Depth It — <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ <br />Grout Seal Depth R ❑ Neat Cement (94 Ib bag/5-90 gal water) ❑ Sand Cement sack <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />111-auea ay u ureter ❑ Pump Contractor <br />❑ Concrete Pedestal ❑Dimensions: Width <br />in ❑ Christy Box ❑ Stove Pipe <br />❑ Other <br />It Length ft Thick <br />41 <br />ruMP '5ubmersble❑ Turbine ❑ Other HP --`-- Pump Set _ It Standing Water Level ft <br />Plot Plan Regfiirements. 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 r— j Date Y�Yb <br />Grout Inspection By Date <br />Pump Inspection By Date::,]— <br />Soil <br />ate Soil Boring Inspection By Date <br />,OMMENTS D� <br />Area y <br />Employee ID#_ fc'r1 <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth ft <br />')-1,Ii4gv <br />r-lecelvea L:neCK#/ Amount Permit/ <br />Codes Info av Cash Remitted Dat Service Re est # Invoice # Well 1D# <br />427-11 T7 <br />D043-06 Ionsr_oa1 / 1 of? <br />11'etl "Puma Permit <br />0 <br />n <br />T <br />z <br />R <br />v' <br />Ic.r <br />