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1 WELL/PUMP PERMIT <br />CAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />IVVIV-KEFUNDABLE PERMIT t:ALL ZU9) 953-7(j97 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 1763 S Hewitt Rd cmy/zIP Linden,CA 95236 <br />CROSS STREET Copperopo l i s RD APN 1 8 3 3 0 0 77 PARCEL SIZE 6 s LAND USE APPLICATION # <br />OWNER NAME BWC Weststeyn, LP PHONE <br />OWNER ADDRESS 1763 S Hewitt Rd CITYISTATE/ZIP Linden,CA 95236 <br />CONTRACTOR Purviance Drillers, Inc PHONF-209-887-3554 <br />PO Box 64 Linden CA 95236' <br />CONTRACTOR ADDRESS CITY/STATEIZIP <br />SUBCONTRACTOR n/ a <br />SUBCONTRACTOR ADDRESS <br />LICENSE )QXC-57 ❑ C-61 ❑ D-09 ❑ Other <br />PHONE <br />CITY/STATE/ZIP <br />NUMBER 3 7 7 9 2 3 EXPIRATION DATE <br />DOMESTIC WELL SAMPLING: = General Mineral/Coliform Bacteria (4391) - Dibromochloropropane (4392) : Arsenic (4393) <br />INTENDED USE ❑ Domestic/Privatep� Irrigation/Agricultural ❑ Industrial El Water Quality Monitoring ❑ Soil Sampling/Characterization <br />E3 Public Water Sys m <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK ❑ New Well ❑ Replacement Well C Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings ❑ Geotechnical : of borings <br />❑ Out -Of -Service Well C Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />❑ New Pump ❑ Pump Replacement Id.PUmp Repair ❑ Raise Well Casino rnRv1v11CK1T <br />WV=LL l.ONSTRUCTIDN r RECEIVED <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger C Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel PacklGravel Siz eter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched n_ Steel ❑ Plastic [I Stainless Steel ❑ Of "} JRONME JOAQLJtN ° TY <br />AR <br />if At r <br />Grout Seat Depth ft n Neat Cement (94 Ib bag15-90 gal water) ❑ Sand Cement sac mix, gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ 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 />lin ❑ Christy Box ❑ Stove Pipe <br />PUMP ❑ SubmersiblEyi•Turbine C Other HP�_ Pump Set (J ft Standing Water Level <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: . -:.. _ ..l ..._ :?; Ft)';}1'Sj=::i ..:i ;S-: i.;:.iSs3 r:i't.e. j_q)) 95'-71,0" <br />Area �/ / Employee ID# <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth ft <br />TV <br />m <br />D <br />0 <br />0 <br />n <br />N <br />PE <br />Codes <br />DEPARTMENT USE ONLY <br />Application Accepted By �i — Z— <br />Date % d" 2 <br />Grout Inspection By <br />_ • .-Date <br />Pump Inspection By �k�/.,�> <br />Date <br />Soil Boring Inspection By <br />Date <br />COMMENTS <br />Area �/ / Employee ID# <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth ft <br />TV <br />m <br />D <br />0 <br />0 <br />n <br />N <br />PE <br />Codes <br />SC Received Check#/ Amount Date <br />Info h Remitted <br />PermlV Invoice # Well ID# <br />ervice Re uest# <br />L4 3 P <br />[? `] <br />. t <br />I <br />EHD0.3-0510:?<l2021 � `I � ����Q � � � / page I cf? <br />W91 /Pump Permit <br />