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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 />Ivvty-r`crurvUrat3LL rtKMI I <br />L ALL (LUU) J03-1UUt FOR INSPECTIONS <br />EXPIRES 1 YEAR FROM DATE ISSUED <br />.JOB ADDRESS <br />_ 5103 E Ashely <br />RD <br />CITY/ZIP St-ockton,CA <br />95212 <br />CROSS STREET <br />N Ruff Rd <br />APNO 8 6 0 7 0 21 <br />PARCEL SIZE 2. 7 1 <br />LAND USE APPLICATION # <br />OWNER NAME <br />Mina Zhu <br />PHONE 51 O 850 9080 <br />OWNER ADDRESS <br />5103 E Ashley <br />Rd <br />CITY/STATE/ZIPStockton, CA 95212 <br />CONTRACTOR <br />Purviance Drillers Inc <br />PHONE209-887-3554 <br />PO Box 64 <br />CONTRACTOR ADDRESS <br />CITY/STATE/ZIP <br />Linden, CA 95236 <br />SUBCONTRACTOR n/ a <br />SUBCONTRACTOR ADDRESS <br />LICENSE X)r-57 ❑ C-61 ❑ D-09 ❑ Other <br />PHONE <br />CITYISTATE/ZIP <br />NUMBER 3 77 9 2 3 EXPIRATION DATE 7/ 31 / 2 3 <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) C, Arsenic (4393) <br />INTENDED USEomestic/Private ❑ Irrigation/Agricultural ❑ 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 ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other 7A I, __ <br />❑ Monitoring Well(s) # of wells ❑Soil Boring(s) # of borings❑ Geotechnical�^9c N <br />111 , <br />/ <br />❑ Out -Of -Service Well Out -Of -Service Well Renewal ❑ Cross -Connection Repair CC.•C� V�� <br />❑ New Pump ❑ Pump Replacement Y. Pump Repair ❑ Raise Well Casino //i, <br />WELL CONSTRUCTION I9q <br />Drilling Method ❑Mud Rotary ❑ Air Rotary ❑ Auger 177Cable Tool 11Push Point ❑ Other SAN J <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Grave! /R B1A7nater <br />ameter I <br />Well Casing DiameerConductor C inin Thickness/Gauge/ASTM Sched Conductor Casing D0 Steel ❑ Plastic 0 Stainless Steel ❑ Other pth ft DE PA RT74 <br />"��TT <br />Grout Seal Depth ft ❑ Neat Cement (941b bag15-10 gal water) C Sand Cement sack mixl7 ga! water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other Fl Retardant / Accalpratnr rnnmel <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />11 Concrete Pedestal ❑Dimensions: Width ft Length ft Thick <br />in ❑ Christy Box ❑ Stove Pipe <br />PUMP Submersible❑ Turbine ❑ Other HP Pump Set 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 />MININIUM 24 HO R ADVANCE NOTICE REQUIRED FOR INSPECTIO-NS - PLEASE CALL (209) 9. -,3 -769 - <br />DEPARTMENT USE ONLY <br />Application Accepted By Date 7 6 ­/ad Area Cif Employee ID# Ffl <br />Grout Inspection By 4 Date ❑ SPECIAL Well Permit <br />Pump Inspection By Date\ c� a1 ❑ WAIVER Received <br />Soil Boring Inspection By Date Constructed Wel Depth_ ft <br />COMMENTS l7c�ct�:►'IF11 rce7rr/ilnea es t5� I..iP��-- �V �'dt� -IZ�� L��3LX <br />rn <br />4 <br />m <br />D <br />a <br />0 <br />m <br />m <br />N <br />N <br />PE <br />Codes <br />SC Check#! <br />Info Cash <br />Amount Date Permit/ Invoice # <br />Remitted Service Re uest # <br />Well ID# <br />38a <br />4Receiveld <br />SO Sa-. <br />Zi <br />r11Uu4d-o0 tws 1LULI Page I oft Well IPnmp Permit <br />�2� 1 `�5G%3 S � <br />