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I WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />sear r.__...'— - <br />�rvvno�c rcrcml l GALL LU9 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />Joe ADDRESS 1 71 80 E Comstock RD L' d <br />ICROSSSTREET Duncan Rd <br />1OWNERNAME Ed Giannecchini Jr <br />IOWNERADDRESS 6888 N Wall Rd <br />%ATT IP in en,CA 95236 <br />APN 0 91 1 6 01 1 PARCEL SIZE 4 0 - 0 LAND USE APPLICATION # <br />CONTRACTOR Purviance Drillers, Inc <br />PO Box 64 <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR n/a <br />SUBCONTRACTOR ADDRESS <br />LICENSE X1 -C-57 ❑ C-61 ❑ D-09 ❑ Other <br />NUMBER <br />PHONE 209 887 3785 <br />CITY/STATEizip Linden,CA 95236 <br />PHONE209-887-3554 <br />CITY/STATFJZIP Linden, CA 95236 <br />CITYISTATEIZIP <br />PHONE <br />EXPIRATION DATE 7/ 3 1/ 2 3 <br />DOMESTIC WELL SAMPLING: 7- General Mineral/Coliform Bacteria (4391) - DihromochinrnnrnnanA (as491 7 arocnir reAo�1 <br />INTENDED USE 0 Domestic lPrivate )if Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br />❑ Public Water System <br />If different from OVmen Water System Name Contact Name or Phone Number <br />r.. <br />.vow weir u nepiacement vven U Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # 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 5t Pump Replacement ❑ Pump Repair ❑Raise Well Casino <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cab(e Tool 0 Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter u Open Bottom ❑ Gravel Pack/Gravel Size in di?meter <br />❑ Conductor Casing in diameter / Conductor Casing Depth —It PAYMENT <br />Well Casing Diameter in ThicknesslGauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ oAFECEIVED, <br />Grout Seal Depth ft 0 Neat Cement (94 lb bag/5-10 gal water] ❑ Sand Cement ck,gll�fT.932 mater <br />0 Bentonite (20% solids) ❑ Other AF <br />Grout Placement Method ❑ Pumped ❑ Free Fall 0 Other ❑ Retardant / Accelerator (name) <br />NJAL <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other „cn0,, oc AaTn+eN <br />❑ Concrete Pedestal ❑Dimensions: Width ft Length ft Thick <br />in ❑ Christy Box ❑ Stove Pipe <br />P MP 0 SubmersiblelA Turbine ❑Other HP_ Pump Set_ ft Standing Water Level �S9 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 B L� Accepted C/^C. <br />P Y Date ' � � � Area Employee <br />Grout Inspection By Date ❑ SPECIAL Well Permit <br />Pump Inspection By 14791 Date 4'� i `L C ❑ WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS o, i; ; Y1 r1^ f C'� p ! y'c7 kS -b <br />PE SC Received <br />Codes Info <br />Check#/ <br />Gash <br />Amount Permit/ <br />Remitted Date S ice Re est <br />Invoice # Well ID# <br />47/ <br />rsruwwTxGVSIPage 1 of 2 Well !Pump Permit <br />-tt l �5 z z 2�v Lv <br />T <br />m <br />m <br />D <br />0 <br />0 <br />rn <br />rn <br />