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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 />IVI.IIV-KEFUNDABLE VERMIT L;ALL (LUU) yb3-(by( FOR INSPECTIONS tAVIKt5 9 YEAR FROM DATE ISSUED <br />JOB ADDRESS 828 S Hewitt Rd CITY/ZIP Linden,CA 95236 <br />CROSS STREET COpperopoI i S Rd APN _1 8 7 0 2 0 0 6 PARCEL SIZE20 _ R 5 LAND USE APPLICATION <br />OWNER NAME Linden Gun Range PHONE <br />OWNERADDRESS 828 S Hewitt Rd CITYISTATEIzIP Linden, CA 95236 <br />CONTRACTOR Purviance Drillers, Inc PHONE209-887-3554 <br />PO Box 64 Linden, CA 95236 <br />CONTRACTOR ADDRESS CITYISTATE/ZIP <br />n/a <br />SUBCONTRACTOR ADDRESS <br />LICENSE )>- -57 E. C-61 D D-09 D, Other <br />P <br />CITYISTATE/ZIP <br />NUMBER 3 7 7 9 2 3 EXPIRATION DATE 7/ 31 / 2 3 <br />DOMESTIC WELL SAMPLING: -- General Mineral/Coliform Bacteria (4391) - Dibromoch(oropropane (4392) = Arsenic (4393) <br />INTENDED USE Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring D Soil Sampling/Characterization <br />Public Water System <br />If different from Ovmer. <br />Water System Name <br />TYPE OF WORK C New Well Fj Replacement Well C Well Alteration/Modification <br />C Monitoring Well(s) of wells ❑ Soil Borings) <br />❑ Out -Of -Service Well ^ Out -O'. -Service Well Renewa <br />C New Pump ❑ Pump Replacement _PumD Repair <br />Contact Name or Phone <br />❑ Other7 r /Np-� <br />rofborings C Geotechnical l; i <br />1 n Cross -Connection Repair 4�^ /CO <br />❑ Raise Well Casino c, . V J9 <br />VVELL CONSTRUCTION FVOq lUZ? <br />Drilling Method = Mud Rotary a Air Rotary 17 Auger C Cable Tool r] Push Point ❑ Other HF 6y QU/ <br />Proposed Well Depth t Excavation in diameter :Open Bottom ❑Gravel Pack/Gravediameter <br />L_ Conductor Casing in diameter I Conductor Casing Depth ft %/y/� <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched M Steel C. Plastic ❑ Stainless Steel � Other Nj <br />Grout Seal Depth ft _ Neat Cement (94 lb bag/5-10 gal water) n Sand Cement sack mixt gal water) <br />Bentonite (20% solids) _ Other <br />Grout Placement Method n Pumped n Free Fall ❑ Other 0 Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller u Pump Contractor Other <br />❑ Concrete Pedestal 0imensions* Width it Length ft Thick <br />lin ED Christy Box Stove Pipe <br />IPu op Submersible❑ Turbine D Other HP=Z_ Pump Set a1jD 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, j <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 />L '12091 <br />D PARTMENT U E ONLY `%n�1 <br />Application Accepted By Date r! ?/`� Y Z Area L (l y v' Employee ID �✓r <br />Grout Inspection By ( ate G''`` SPECIAL Well Well Permit <br />Pump Inspection By S Date Q WAIVER Received <br />Soil Boring Inspection By <br />COMMENTS <br />Date Constructed Well Depth <br />PE Sc Received Checkn/ Amount Permit/ <br />o Info B Cash Remitted ate Service Request Invoice Well IDT <br />7 1 I I 1 <br />I i l I i l <br />! I I <br />ft <br />EHDt7-.'3-05 10:'35,'202 1 Pagc 1 of 2 U'tll i Punn Penmt <br />W, <br />m <br />0 <br />0 <br />0 <br />N <br />V: <br />