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I WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />INUly-rxtl-UNUAtiLL rtKMIT L;ALL (ZUU) Ub3-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOBADDRES� 14250 E St Rt Hwy 26 cITY/zIP_ Stockton,CA 95212 <br />CROSS STREET Fanning Rd APN - 10507002 PARCEL SIZE2 0 • 6 8 'LAND USE APPLICATION # <br />OWNER NAME Biff Gilliland �C,�hf i` t7 'f ((lIN! I Iy Lr�►��� ``-f PHONE <br />OWNERADDRESS 14404 E Highyway 26 CITY/STATE/ZIP Linden,CA 95236 <br />CONTRACTOR Purviance Drillers, Inc PHONE209-887-3554 <br />PO Box 64 Linden, CA 95236 <br />CONTRACTOR ADDRESS CITY/STATE/ZIP <br />SUBCONTRACTOR n/ a <br />SUBCONTRACTOR ADDRESS <br />LICENSE }IXC -57 ❑ C-61 ❑ D-09 ❑ Other <br />CITY/STATE/ZIP <br />NUMBER 377923 EXPIRATION DATE 7/ 31 / 2 3 <br />DOMESTIC WELL SAMPLING: -- General Minera(lColiform Bacteria (4391) _ Dibromochloropropane (4392) 7 Arsenic (4393) <br />INTENDED USE ❑ Domestic/PrivateIrrigation/Agricultural ?DIndustrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterizalion <br />❑ Public Water Syst <br />If different from Owner. Water System Name Contact Name or Phone Number <br />TYPE OF WORK ❑ New Well ❑ Replacement Well G Well Alteration/Modification ❑ Other <br />C Monitoring Well(s) # of wells ❑ Soil Borings) # of borings ❑ Geotechnical # of borings <br />❑ Out -Of -Service Well C Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />11 New Pump D Pump Replacement 5(PumD Repair ❑ Raise Well Casino <br />Drilling Method Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool F: Push Point C Other <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size �p,�{ eter <br />C Conductor Casing in diameter / Conductor Casing Depth ft 90- <br />RECEIVED <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth ft ❑ Neat Cement (94 lb bagl5-10 gal wafer) ❑ Sand Cement i k?ixf ali22ter <br />Bentonite (20% solids) ❑ Other ZULL <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant /Accelerator (name) ,AN JOAOU(N COUNTY <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor <br />❑ Concrete Pedestal ❑Dimensions: Width_ <br />in ❑ Christy Box ❑ Stove Pioe <br />D Other_ <br />ft Length <br />ft Thick <br />PUMP ❑ SubmersiblTurbine G Other HPPump Set_l)ft Standing Water Leve( 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 />_.,.._.__.s._aliia:_.,t?itepi:C:ii)'S-?L_..`,5CALL (209 - -:I- <br />Application Accepted By <br />IV, <br />DEPARTMENT USE ONLY <br />Date ?/-0/?d <br />Area L1/ Employee ID# <br />Grout Inspection By <br />Pump Inspection By <br />/'r( <br />ate <br />% <br />D.te22M — <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Soil Boring Inspection By <br />COMMENTS Cc':'11 <br />" (.Oof; 1 L761 <br />Date <br />KS i " vJP 0- <br />Constructed Weli Depth ft <br />T <br />m <br />0 <br />0 <br />X <br />N <br />PE <br />Codes <br />SC Received Check#! <br />Info B a <br />Amount <br />Remitted Date <br />Permit! <br />Service Re uest # Invoice # Well ID# <br />+7 7 <br />EHD043-06 IV --5!3031 / q / '' '� C yJ %_ �/ Z r12-2-- Pace I ort Well IPump Permit <br />