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to <br />�+ <br />WELUPUMP PERMIT <br />. AN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br />DEPARTMENT <br />NON-REFUNDABLE PERMIT <br />1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOBADDRESS 16167 E Eight <br />Mile Rd <br />Cm/Z1PLinden, CA 95236 <br />CROSS STREET 21,1 1 Y R d <br />ApN 0 6 5 0 9 0 31 PARCEL Sim 4. 7 LAND USEAPPL1CA770N# <br />OWNER NAME S01 ari Ran --h PrOdllCe <br />PHONE 2098879611 <br />OWNER ADDRESS PO BOX 477 <br />Crnr/STATEOP L I n d e n, CA 95236 <br />CONTRACTOR Purviance Drillers, Inc <br />PO Box 64 <br />PHONE209-887-3554 <br />CONTRACTORADDRESS <br />CITYISTATE/Z1P Linden, CA 95236 <br />SUBCONTRACTOR nI a <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />Cr Y/STATEIZIP <br />LICENSE AC -57 ❑ C-61 ❑ D-09 <br />❑ Other NUMBER _377923 EXPIRATION DATE <br />DOMESTIC WELL SAMPLING: 7 General Mineral/Coliform Bacteria (4391) pibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE Domestic/Private 0 Irrigation/Agricultural ❑ Industrial 0 Water Quality Monitoring ❑ Soil SamplinglCharacter¢atian <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 0 Soil Borings)tr of borings <br />FJ Out -Of -Service Well ❑ Geotechnical ���gs <br />❑ Out OfService Well Renewal ❑ Cross -Connection Repair <br />❑ New PumD I& Pumn Ranlmrvrnn --- <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cabld Tool 0 Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter D Open Bottom ❑ Gravel Pack/Gravel Size <br />0 Conductor Casing in diameter / Conductor Casing Depth <br />Well Casing diameter ft in Thickness/Gauge/ASTM Schell ❑Steel ❑Plastic ❑Stainless Steel ❑Outer y <br />Grout Seal Depth ft 0 Neat Cement (941b bag/5-10 gal water) ❑ Sand Cement <br />❑ Bentonite (20% solids) 0 Other sack a a ell <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Othern" CO <br />❑ Retardant /Accelerator (name) en,vir+or, � <br />Tr <br />r?DESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />In <br />❑ Concrete Pedestal ❑Dimensions: Width ft Length ft Thick <br />❑ Christy Box 0 Stove Pipe <br />t'UMP 'ASubmersible❑ Turbine 0 Other <br />HP�i Pump Set _ it Standing Water Level _l`,5 (p _ ft <br />Piot Plan Requirements: Attach a plot pian 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 Dat �t .� Area ( LJ <br />�� C�{ci i1 <br />Grout Inspection ByL Employee ID# <br />Date ❑ SPECIAL Well Permit <br />Pump Inspection By -A- Date Z <br />❑ WAIVER Received <br />Soil Boring Inspection By Date <br />;OMMENTS Dv- , !n N i� (' i y! t; F - I Constructed Well Depth if <br />�jYV` N 1 6&� %Ga 1�/ yL /� - \Yell/?=pp,.i! <br />v <br />0) <br />