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1 WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />�v..— „icL-c r-CKMI I t ALL (lU9) 953-7697 FOR INSPEC11ONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JoeADDRESs 454 N Holden Rd Cmr21P Linden.CA 95236 <br />CROSS STREET Milton RD APN 1 0 51 1 0 4 7 PARCEL SIZE � 6 t O(1 LAND USE APPLICATION # <br />OWNER NAME John Dondero Farms IncP(a10 ThOAW1s' gu4ft'A PHONE 1� 7U �, q <br />OWNER ADDRESS 17 7 6 N Murrav RCI CITY/STATEOP Linden, CA 95236 <br />CONTRACTOR Purviance Drillers Inc <br />PO Box 64 <br />CONTRACTOR ADDRESS CITY/STATEMP <br />SUBCONTRACTOR n/a <br />SUBCONTRACTOR ADDRESS CITY/STATE21P <br />LICENSE )PP57 ❑ C-61 ❑ D-09 ❑ Other <br />. PHONF-209-887-3554 <br />Linden, CA 95236 <br />PHONE <br />NUMBER 377923 EXPIRATION DATE <br />UUMeSTIC WELL,AMPLING: General Mineral/Coliform Bacteria (4391) C Dibromochloropropane (4392)!D Arsenic (4393) <br />INTENDED USE `�DomestWPrivate ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br />0 Public Water System <br />If different from Owner. <br />Water System Name 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) # of borings ❑ Geotechnical <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair p� C <br />❑ New Pum um Replacement 0 Pum Repair 0 Raise Well Casingr'7 <br />WELL CONSTRUCTION <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary 0 Auger 0 Cable Tool ❑ Push Point D Other S AF JOA p <br />ProposedweDepth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel V6��e i r� <br />0 Conductor Casing in diameter / in <br />Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic 0 Stainless Steel <br />Grout Seal Depth ft D Neat Cement (94 1b bag/5-10 gal water) ❑ Sand Cement <br />❑ Bentonite (20% solids) 0 Other <br />Grout Placement Method ❑ Pumped D Free Fall 0 Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal DDimenslons: Width ft Length ft Thick <br />in ❑ Christy Box ❑ Stove Pipe <br />I <br />❑ Other <br />sack m&7 gal water <br />PUMP X Submersible❑ Turbine 0 Other HP Pump Set `'h ft Standing WaterLevel ft <br />Piot 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 />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By titi'D✓ <br />Soil Boring Inspection By <br />Z <br />DEPARTMENT USE ONLY <br />Date 3 <br />Date <br />Date <br />Area 3 9q Employee ID#A-< <br />❑ SPECIAL Well Permit <br />D WAIVER Received <br />Constructed Well Depth ft <br />PE <br />Codes <br />SC Received Check#/ <br />Info By Cash <br />Amount <br />Remitted )ate <br />Permit/ <br />Service Re uest # Invoice # Well ID# <br />381 <br />OS -0 <br />4 7 .2- ry <br />,r 4 - y s <br />-'- -- •- -•`• J Page 1 ort Wel/Pump Permit <br />T <br />m <br />A <br />rn0 <br />rn <br />T <br />