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I WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOBAODRESS 14740 Alpine RD CITY/ZIPLOdi,CA 95240 Amount Date Permit/ Invoice # Well ID# Remitted Service Re uest # CROSS STREET Ke t t l eman Ln APN 0 6 3 0 7 0 4 8 PARCEL SIZE 5. 1 1 LAND USE APPLICATION # OWNER NAME John Teresi jA wt� V PHONE_ OWNERADDRES,' 14740 Alpine Rd / �•IJ J� (I �(� CITY/STATFJZIPLodi, CA 95240&1,-1; I I CONTRACTOR Purviance Drillers, Inc PHONE209-887-3554 PO Box 64 Linden, CA 95236 CONTRACTOR ADDRESS CITY/STATEIZIP SUBCONTRACTOR n / a PHONE SUBCONTRACTOR ADDRESS CITYISTATEIZIP LICENSE ,PAC -57 ❑ C-61 ❑ D-09 t7 Other NUMBER 377923 EXPIRATION DATE 7/ 31 / 2 3 DOMESTIC WELL SAMPLING: - General Mineral/Coliform Bacteria (4391) . Dibromochloropropane (4392) ` Arsenic (4393) INTENDED USE L Domestic/Private iIrrigation/Agricultural ❑ Industrial Water Quality Monitoring ❑ Soil Sampling/Characterization Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK ❑ New Well C Replacement Well ❑ Well Alteration/Modification ❑ Other ❑ Monitoring Well(s) # of wells C Soil Boring(s) # of borings ❑ Geotechnical El Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair ` V E New Pum Pum Replacement [i Pum Repair ❑ Raise Well Casing J WELL CONSTRUCTION SA/V'/QQ OZ Drilling Method E Mud Rotary i 1 Air Rotary ❑ Auger 7lCable Tool ElPush Point ❑ Other 1. Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel SIZ q k t'eql� Conductor Casing in diameter / Conductor Casing Depth t PIRTh1E Well Casing Diameter in Thickness/Gauge/ASTM Sched 11 Steel 11 Plastic Ll Stainless Steel a Other N Grout Seal Depth ft ] Neat Cement (94 lb bagl5-10 gal water) _ Sand Cement sack mixt gal water L Bentonite (20% solids) Other Grout Placement Method a Pumped ❑ Free Fall ❑ Other E Retardant / Accelerator (name) PEDESTAL Installed By ❑ Driller G Pump Contractor _ Other Concrete Pedestal ❑Dimensions: Width ft Length ft Thick lin _ Christy Box E Stove Pipe PUMP Submersible❑ Turbine E Other HP Pump Set ft Standing Water Level _ P Plot Plan Requirements: Attach,a plot plan with the exact location of water well with respect to the following items: GPS Coordinates, property lines, adjoining properties, water bodies or courses, drainage pattern, roads, existing wells, structures, potential sources of contamination, sewers or private disposal systems. Include distance from two property lines. For Domestic, Agriculture, Industrial well, provide location of any water wells or surface water within 200' radius of proposed well. NIENIN11" I'_-1 HOURADVANCE ANNE NOTIf E RIP,?1 IRED FOR 11SPEX'TTONS - PLEASE CALL ('_m)1953-769; ,s+�J J ) DEPARTMENT USE ONLY {- Application Accepted By l /= = �•_ L _ Date rz +� Area r/ C C Employee ID# f -� °q �` Grout Inspection By 4 Date D SPECIAL Well Permit Pump Inspection By ll Date & [I WAIVER Received Soil Boring Inspection By Date Constructgd Well Depth ft COMMENTS 3l (� ' LZ l ��L� j 7 r PESC Received Check#! Codes Info ByzfN Cash Amount Date Permit/ Invoice # Well ID# Remitted Service Re uest # 3£?1 I I EHD043-06 10/-15,'2021 Pagc 1 of 3 Wdl /Pump Pemrt &P l�S/ll 7s8