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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209) 4683420 <br />-rrr-rulVUAt3Lt rt_Kml r GALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />Joe ADDRESS 770`7 Podesta Ln J Crry/ZIP Lind_en,CA 95236 <br />CROSS STREET - St Rt Hwy 26 APN <br />1 PARCEL SIZE s 70 LAND USE APPLICATION # <br />OWNER NAME POdeSta Bros �;�CIts.fci i'r!'rl t rl,,k PHONE <br />OWNERADDRESS 8000 N POdesta Ln CITY/STATEIZIP_L_inden,CA 95236 <br />CONTRACTOR Purviance Drillers, Inc PHONE209-887-3554 <br />CONTRACTOR ADDRESS O BOX 64 Linden, CA 95236 <br />CrrY/STATE21P <br />SUBCONTRACTOR nIa <br />PHONE <br />SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br />LICENSE XaAC-57 ❑ G-61 ❑ D-09 ❑ Other NUMBER 377923 EXPIRATION DATE 7J 3 1 2 3 <br />UOMESTIC WELL SAMPLING: 7 General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) D Arsenic (4393) <br />INTENDED USE ❑ DomesticfPrivate - rrigation/Agricultural D 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 ❑ Other 14 <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s)v of borings o s <br />❑ Geotechnical Q�"t ,C <br />❑ Out -Of -Service Well .D,/ Out -Of -Service Well Renewal ❑ Cross -Connection Repair p, / D <br />❑ New Pump ❑ Pump Replacement 'Chump Repair ❑ Raise Well Casino Md y n .. <br />---- -- <br />S4 IV J0,4 <br />Drilling Method Ll Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other E Oq QU <br />Proposed Well Depth ft Excavation in diameter u Open Bottom ❑ Gravel Pack/Gra v ��r, Vrheter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft R T <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other MENT <br />Grout Seal Depth ft ❑ Neat Cement (94 lb bag/5-90 gal water] ❑ Sand Cement sack mix17 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method D Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal ❑Dimensions: Width ft Length ft Thick <br />in ❑ Christy Box ❑ Stove Pipe <br />PUMP ❑ Submersibles Turbine ❑ Other HP 'i Pump Set 7M, <br />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 s Area <br />/ i Employee ID# 1 r1 k <br />Grout Inspection By Date ❑ SPECIAL Well Permit <br />Pump Inspection By Date ZTI - l_ <br />1 ❑ WAIVER Received <br />Soil Boring Inspection By <br />COMMENTS_ <br />Date <br />Constructed Well Depth ft <br />PE <br />Codes <br />SC Received <br />Info B <br />Check#/ <br />Cash <br />Amount Date <br />Remitted <br />Permit/ <br />Service Re uest # Invoice # Well ID# <br />Pae I of t <br />� \Yell !Pump Permi: <br />- 1 �z8'o1g 70 <br />T <br />m <br />D <br />0 <br />0 <br />m <br />W <br />N <br />