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1, WELL/PUMP PERMIT <br />i 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 1 YEAR FROM DATE ISSUED <br />JOBADDRESS 7900 N Jacktone Rd cITYrzIP Stockton,CA 95215 <br />CROSS STREET Comstock Rd APN 0 91 0 2 0 3 2 PARCEL SIZE1 . 2 9 LAND USE APPLICATION # <br />OWNER NAME Aldo Freggiaro PHONE Z4- <br />2� <br />OWNERADDRESS 7900 N Jacktone RD CITYISTATEIZIPStockton,CA 9521 5 <br />CONTRACTOR Purviance Drillers INC PHONE 209 887 3554 <br />CONTRACTOR ADDRESS P.O. BOX 64 CITYISTATE/ZIP Linden,CA 95236 <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br />LICENSE XC -57 ; C-61 n D-09 11 Other NUMBER 37792 3 EXPIRATION DATE 0 7/ 31 / 2 3 <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE omestic/Private n Irrigation/Agricultural 1! Industrial i ; Water Quality Monitoring r, Soil Sampling/Characterization <br />Public Water System <br />If different from Owner" Water System Name Contact Name or Phone Number <br />TYPE OF WORK n New Well n Replacement Well it Well Alteration/Modification n Other <br />i': Monitoring Well(s) # of wells I I Soil Boring(s) of borings 1i Geotechnical <br />11 Out -Of -Service Well F! Out -Of -Service Well Renewal 11 Cross -Connection Repair <br />i? New Pump i?ump Replacement [1 Pump Repair I-] Raise Well Casing <br />WELL CONSTRUCTIONA Y ry <br />Drilling Method i i Mud Rotary C Air Rotary R Auger Cable Tool Push Point Other_ SAA `i <br />Proposed Well Depth ft Excavation in diameter n Open Bottom n Gravel Pack/Gravel S Ze q Q(� diameter <br />F E <br />Conductor Casing In diameter / Conductor Casing Depth ft H ALT r y 14l CC ON/ <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched ;1 Steel Cl Plastic I1 Stainless Steel it Other "ARTA­ <br />Groutut Seal Depth It n Neat Cement (94 Ib bagl5-10 gal water) n Sand Cement sack mixl7 gal wa <br />fg <br />i I Bentonite (20% solids) it Other <br />Grout Placement Method n Pumped F1 Free Fall i ; Other 1-1 Retardant / Accelerator (name) <br />PEDESTAL Installed By ,- Driller n Pump Contractor n Other <br />n Concrete Pedestal neimensions: Width ft Length ft Thick <br />�in 11 Christy Box Ll Stove Pipe <br />PUMP Submersibles Turbine P Other HP Pump Set ft Standing Water Level 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 Accepted By �� Date Sla 11115a Area / Employee ID# f N� <br />Grout Inspection By Date ❑ SPECIAL Well Permit <br />Pump Inspection By Date �- L2!✓ G WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS L>pLUr'►' e, t" od r rnLnJ 101t .Je <br />T <br />m <br />D <br />0 <br />0 <br />M <br />M <br />N <br />y <br />PE <br />Codes <br />SC Received <br />Info <br />Check#/ <br />Cash <br />Amount <br />Remitted <br />Date PermiU Invoice # Well ID# <br />= Service Re uest# <br />y3e 1sa <br />- <br />-77 <br />FIID0.43-06 0.4i072022 �/'`�� Pale loft \Pell; Pump Permu <br />