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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />— <br />.vviv--�FU LJADLC r CKlyili LHL-L (ZUU) y33-T6y( FOR INSPECTIONS EXPIRES i YEAR FROM DATE ISSUED <br />fir_ <br />J02 ADDRESS 246 S Reid Rd CITY/ZIP r 7 ndenf CA A 5 2� 6 <br />CROSS STREET _ E Sara Ln _ APN _ 183360'33 PARCEL SIZE�_LANO USE APPLICATION ± i <br />04VNERNAME Carnl DL-rksnn PHONE I <br />OWNERADDRESS 246 S Reid Rd CITYISTATEIZIP LindPn-CA 9923h <br />CONTRACTOR Purviance Drillers, Inc PHONE 209-887-3554 <br />PO Box 64 Linden, CA 95236 <br />CONTRACTOR ADDRESS CITYISTATE/ZIP <br />SUBCONTRACTOR, n/a Punic <br />SUBCONTRACTOR ADDRESS <br />LICENSE IXC -57 L C-61 ❑ D-09 D Other <br />CITYISTATE/ZIP <br />NUMBER 3 7 7 9 2 3 EXPIRATION DATE 7/ 31 / <br />DOMESTIC WELL SAMPLING: = General Mineral/Coliform Bacteria (4391) - Dibromochloro propane (4392) — Arsenic (4393) <br />INTENDED USE I Domestic/Private D Irrigation/Agricultural D Industrial D Water Quality Monitoring D Soil Sampling/Characterization _ Public Water System <br />If different from Oemer. Water System Name Contact Name cr Phone Number <br />TYPE OF WORK <br />C New Well a Replacement Well Well Alteration/Modification D Other <br />u Monitoring Well(s) 9 of wells D Soil Boring(s) f? of borings 0 Geotechnical <br />❑ Out -Of -Service Well Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />D New Pump Pump Replacement C Pump Repair 11 Raise Well Casino <br />WELL CONSTRUCTION <br />Drilling Method ^ Mud Rotary Air Rotary D Auger Cable Tool C Push Point C Other , <br />Proposed Well Depth ft Excavation in diameter 0 Open Bottom 0 Gravel Pack!Gravel S <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched = Steel ❑ Plastic 0 Stainless Steel <br />Grout Seal Depth ft C Neat Cement (94 Ib bag/5-90 gal water) (2 Sand Cement <br />Bentonite f20% solids) _ Other <br />Grout Placement Method C, Pumped D Free Fall a Other D Retardant / Accelerator (name) <br />� Other `~ARTMENT <br />sack mix17 gal water <br />PEDESTAL Installed By ❑ Driller D Pump Contractor ❑ Other <br />❑ Concrete Pedestal -Dimensions: Width ft Length ftThick <br />in ED Christy Box a Stove Pioe — <br />PUMP Submersible- Turbine G Other HP--------- <br />PumpSete U f# Standing Water Level ft <br />PIot 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 tivetls, 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 />.. U.- .., _ ... ; _ . �:.....-- - - ... ;_q:t • ::- . - <br />PARTMENT E ONLY D <br />Application Accepted By Date Area -L Employee ID, <br />E <br />Grout Inspection By Date t PECIAL Well Permit ` <br />Pump Inspection By - 7 Date ( C) C1 WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />T <br />41 <br />PE SC Received Checkftl Amount Permitt <br />COCWS Info Cash R miffed D e Service Re uest # Invoice # Well 1D#IVI <br />1A <br />- — <br />Pz- I of 1Fe:i; Pump Pemnt <br />