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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 />1XVIN-r'-LINLIAtiLt PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />�JOBADDRESS 17450 Wagner Ln C►TY21P Linden,CA 95236 <br />CROSS STREET Duncan RD APN 10510006 PARCEL SIZE LAND USE APPLICATION# <br />OWNERNAME Podesta Bros PHONE <br />OWNERADDRESS 8000 N POdesta Ln <br />CONTRACTOR Purviance Drillers, Inc <br />PO Box 64 <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR n/ a <br />SUBCONTRACTOR ADDRESS <br />LICENSE Xa)�C 57 0 C-61 ❑ D-09 7 Other <br />CITY/STATE21P Linden,CA 95236 <br />PHONE209-887-3554 <br />CITYiSTATEmP Linden, CA 95236 <br />PHONE <br />CITY/STATEOP <br />77923 EXPIRATION DATE 7/31 /23 <br />DOMESTIC WELLSAMPUNG: General Mineral/Coliform Bacteria (4391)Dibromochloropropane (4392) 2 Arsenic (4393) <br />INTENDED USE ❑ Domestic/Private Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Ovmer. Water System Name Contact Name or Phone Number <br />TYPE OF WORK ❑ New Well 0 Replacement Well ❑ Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells 0 Soil Boring(s)# of borings fi <br />ngs ❑Geotechnical ED <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />❑ New Pump ❑ Pump Replacement Pump Repair ❑ Raise Well Casino IAV n — <br />WELL CONSTRUCTION <br />Drilling Method ❑ Mud Rotary 0 Air Rotary ❑ Auger 0 Cable Tool ❑ Push Point 0 Other SAN SDA <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Grav NM df <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft ARTMsNT <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel 0 Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth ft 0 Neat Cement (94 lb bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method 0 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 0 Submersible'f�,Turbine ❑ Other HP �_ Pump Set ft Standing Water Level I 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 e=—.P— Z �— <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />Date <br />Date <br />Date Z <br />Date <br />Area C%Employee ID#M_ <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth ft <br />PE <br />Codes <br />Sc Received <br />Info <br />Check#/ <br />Cash <br />Amount <br />Remitted <br />Date <br />Permit/ Invoice # Well ID# <br />Service Request # <br />END043-06 10P -Sr -2021 Page I of 2 Nell ! Pump Permit <br />T <br />m <br />D <br />O <br />O <br />m <br />w <br />to <br />