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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 />NUN-rCEFUNDABLE PERMIT UALL (ZUU) y03-1 WJI FOR INSPECTIONS CAI 1111=0 7 T EAR I -RUM UATE ISSUED <br />JOBADDRESS 4944 Leonardini RD CITY21P Stockton,CA 95215 <br />CROSS STREET Cherrvland Ave APN0 8 7 0 6 01 4 PARCEL SIZE • 4 5 LAND USE APPLICATION #//�� <br />OWNERNAME Jim Davis 1 PHONE yJ� I 7-V� b �� ` <br />OWNERADDREss 4944 Leonardini RD CITYmSTATE/ZIP Stockton,CA 95215 <br />CONTRACTOR Purviance Drillers, INC PHONF-209 887 3554 <br />CONTRACTOR ADDRESS P.O. Box 64 CITYISTATEIZIP Linden , CA 95236 <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE fkC-57 :: C-61 n D-09 11 Other. <br />PHONE <br />CITYISTATE/ZIP <br />NUMBER 3 7 7 9 2 3 EXPIRATION DATE 7/ 31 / 2 3 <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE omestic/Private i1 Irrigation/Agricultural I! Industrial n Water Quality Monitoring n Soil Sampling/Characterization <br />F) Public Water System _ <br />If different from Owner. Water Svstem Name Contact Name or Phone Number 0- A <br />TYPE OF WORK <br />H New Well n Replacement Well Ci Well Alteration/Modification n Other <br />l Monitoring Well(s) # of wells fi Soil Boring(s) ; of borings n Geotechnical <br />I Out -Of -Service Well %; Out -Of -Service Well Renewal f Cross -Connection Repair <br />t1 New Pump :) PumD ReDlacement 'lkPumD Repair n Raise Well Casino <br /># gs <br />SqN 2 4 <br />WLL <br />Drill ng Method Tr ll Mud Rotary �1 Air Rotary n Auger / ft Cable Tool n Push Point C Other ��AC�N pEp Q1 4t <br />Proposed Well Depth ft Excavation in diameter Di Open Bottom n Gravel Pack/Gravel Size in di6HIWO <br />1 Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched t; Steel F1 Plastic I"l Stainless Steel it Other <br />Grout Seal Depth ft n Neat Cement (94 Ib bag/5-10 gal water) n Sand Cement sack mix17 gal water <br />i i Bentonite (20% solids) Fl Other <br />Grout Placement Method Fl Pumped 'L-) Free Fall i ; Other n Retardant / Accelerator (name) <br />PEDESTAL Installed By n Driller f 1 Pump Contractor n Other <br />i: Concrete Pedestal Fl Dimensions: Width ft Length ft Thick <br />in n Christy Box Stove Pipe <br />PUMP NV Submersiblen Turbine n Other HP I_ Pump Set__k_t I It Standing Water Level 1 U0 It <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 <:f�_ L Z__ Date S 23h�2 Area y fg I Employee ID# Fr,, nk <br />Grout Inspection By A A Date ❑ SPECIAL Well Permit <br />Pump Inspection By Z Date & Z 27 ❑ WAIVER Received <br />Soil Boring Inspection By Date Co structed Well Depth ft <br />COMMENTS D-oK,1rleni Cesar lrlal Psofy✓f, T)C?� 1G � -(7 (: I <br />T <br />m <br />D <br />0 <br />0 <br />z <br />M <br />y <br />Ar <br />PE Sc Received <br />Codes Info By_ <br />Check#/ <br />Cash <br />Amount Date Permit/ Invoice# Well ID# <br />Remitted Service a uest# <br />X13 ga so Z7E10r�, <br />I <br />IIiDO43-06 Q1:07r'2022��/r/ n --# � ���� � � � PSC l of ^_ Well; Pump Pemrit <br />