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4 f•` -j114 <br />SAN.IOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ELL/PUMP PERMIT <br />1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 5606 Leonardini Rd <br />CITY17iP Stockton,CA 95212 <br />CROSS STREET Arm P r-StAPN 08713001 PARCEL SIZE . 4 O <br />LAND USE APPLICATION # <br />OWNER NAME _ Russel. Puckett PHONE209 329 2466 <br />OWNER ADDRESS _ 5606 Leonardini Rd CITY/STATe1zIPStockton,CA 95212 <br />CONTRACTOR Purvi ance Drillers. Inc <br />PO Box 64 PHONF-209-887-3554 <br />CONTRACTORADDRESS CITY/STATE/ZIP Linden, CA 95236 <br />SUBCONTRACTOR n/ a <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />CITY/STATE/ZIP <br />LICENSE X:XC-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER 377923 <br />EXPIRATION DATE -ZL3112 <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) 2 Dibromochloropropane (4392) =1 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 <br />Contact Name or Phone Number <br />TYPE_ OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) 0 or borings ❑ Geotechnical # ofpol* <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair /''M <br />❑ New Pump Pump Replacement ❑ Pump Repair ❑Raise WeII Casln F/� <br />WELL CONSTRUCTION �` 4 p/.N <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel <br />Grout Seal Depth ft ❑ Neat Cement (94 /b bag/5-90 gal water) ❑ Sand Cement <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other <br />❑ Retardant /Accelerator (name) <br />o� <br />oy u urmer u Hump Contractor ❑ Other <br />❑ Concrete Pedestal ❑Dimensions: Width ft Length ft Thick <br />in ❑ Christy Box ❑ Stove Pipe <br />APR / <br />in di W <br />N� NV�Rp UlN CO <br />❑ tN NMN �N <br />sack m��ib�t� <br />Pump 'VSubmersible❑ Turbine ❑ Other HP Pump S 1 <br />t Standing Water Level `1 9 ft <br />Not Plan Regirements 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 />Dotential sources of contamination, sewers or private disposal systems. Inciude distance from two property lines. For Domestic, <br />kgriculture, 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 — � Z Date w Area / �� �% Employee ID# �.7 <br />Grout Inspection By Date 7 ❑ SPECIAL Well Permit <br />Pump Inspection By - Date y _ t t A <br />❑ WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth <br />OMMENTS ft <br />PE I SC Received <br />D0.73-06 10125!2021 <br />CashRemitted Date I r ermiu <br />Service Request # Invoice # Well ID# <br />60— 1477 Z illr i t; '�I <br />1t'etl ! Puma Pcmiit <br />