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'f <br />�1 WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />IMUIN-Mtt-UNUAtiLt rI=RMI I GALL (LUV) Ub3-/1by1 FOR INSPECTIONS LXF'IKES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 9409 St Rt Hwy 88 CITY/ZIP Stockton, CA 95215 <br />CROSS STREET Bogg i ano Rd ApNO 8 9 0 6 0 5 5 PARCEL SIZE 1 .51 LAND USE APPLICATION # <br />OWNER NAME Lawrence Sambado PHONE <br />OWNER ADDRESS P.O. Box 461 <br />CONTRACTOR Purviance Drillers, Inc <br />PO Box 64 <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR n / a <br />SUBCONTRACTOR ADDRESS <br />LICENSE XIXC-57 0 C-61 ❑ D-09 ❑ Other <br />CITY/STATEIZIP Linden, CA 95236 <br />PHONE209-887-3554 <br />CITY/STATEIZIP Linden, CA 95236 <br />P <br />CITY/STATEIZIP <br />NUMBER 377923 EXPIRATION DATE 7/ 31 / 2 3 <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) _ 1 Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE' <br />Domestic/Private ❑ Irrigation/Agricultural El Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br />/] `Public Water System <br />If different from Owner. Water System Name Contact Name or Phone Number <br />TYPE OF WORK ❑ New Well i-. Replacement Well ❑ Well AlterationlModification 0 Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings ❑ Geotechnical <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair i QED <br />New Pump 0 Pump Replacement $Pump Repair ❑ Raise Well Casino 11 a .. _ <br />Drilling Method ❑ Mud Rotary 0 Air Rotary ❑ Auger Cl Cable Tool 0 Push Point ❑ Other SAN J <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravei �IRONMa� i�t�r <br />[IConductor Casing indiameter I Conductor Casing Depth ft IL7 CERARTMENT <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel 0 Plastic ❑ Stainless Steel 0 Other <br />Grout Seal Depth ft ❑ Neat Cement (94 lb bag/5-10 gal water) ❑ Sand Cement sack mix17 gal water <br />❑ Bentonite (20% solids) 0 Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed ❑Driller ❑Pump Contractor C Other <br />11 Concrete <br />Pedestal ❑Dimensions: Width ft Length ` ft Thick <br />�in C Christy Box ❑ Stove Pipe <br />PUMP 1,SubmersibleD Turbine ❑ Other HP'I Td-' Pump Set S' � ft Standing Water Level 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 />MININII M 34 HOUR AD1',kN('i: NOTICE RFQ IRBD FOR INSPLU I'10'\S - Pl.l::aSl: C.kl.l, (209) 953-7697 <br />/ DEPARTMENT USE ONLY <br />Application Accepted By —Z�lr Date S� <br />Grout Inspection By Date <br />Pump Inspection By Date <br />Soil Boring Inspection By Date <br />COMMENTSC)o( ,"'o 1Cr elan f /YIc't A_S __ WIQ � . <br />T <br />Area 64/9 / Employee ID# <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth <br />ft <br />PE <br />Codes <br />SC Received <br />Info B <br />Check#/ <br />Cash <br />Amount PerPermit/# <br />a e <br />Remitted Service Re uest# Invoice Well ID# <br />g31"O <br />oSo <br />$7 <br />ERD043-06 10/25/2021 —4 Parc I of 2 <br />nw 145g3S �" Yell/Pump Permit <br />