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G <br />f WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE -STOCKTON CA 95205 - (209) 468-3420 <br />rvvrv-rctrulvuAr3Le rr_Kmn GALL (LUS) Sb3-f OW FOR INSPECTIONS LAVIKtJ 1 YEAR FROM DATE ISSUED <br />JOBADDRESS 1890 S Hewitt Rd CITY/ZIP Linden, CA 95236 �i <br />CROSS STREET St Rt Hwy 4 /Ap PN 18703006 PARCEL SiZr.3 5 7. 6 BLAND USE APPLICATION # <br />OWNERNAME R & J Sanauinetti / JOSN. i'� q} dariF' 4J 3y7' (1PHONE <br />OWNERADDRESS 18505 E Copperopolis Rd CITYISTATEIZ1PLinden, CA 95236 <br />CONTRACTOR Purviance Drillers, Inc PHONE209-887-3554 <br />PO Box 64 Linden, CA 95236 <br />CONTRACTOR ADDRESS CITY/STATE/ZIP <br />SUBCONTRACTOR n/a <br />SUBCONTRACTOR ADDRESS <br />LICENSE )QXC-57 C C-61 ❑ D-09 ❑ Other <br />PHONE <br />CITYISTATE/ZIP <br />NUMBER 377923 EXPIRATION DATE 7/ 31 / 2 3 <br />DOMESTIC WELL SAMPLING: = General Mineral/Coliforrn Bacteria (4391) _ DibromochlorooroDane (4392) Arsenic (4393) <br />INTENDED USE Domestic/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 C Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings 0 Geotechnical # of borings <br />❑ Out -Of -Service Well ❑ Out-Of-�ervice Well Renewal ❑ Cross -Connection Repair <br />D New Pump "Pump Replacement ❑ Pump Repair ❑ Raise Well Casino <br />WELL CONSTRUCTION f <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool [-I Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter D Open Bottom ❑ Gravel Pa �p ���T in diameter <br />C Conductor Casing in diameter / Conductor Casing Depth ft cMCVrIW E T <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ StainieRStet4Y EJ 6l E I]l <br />Grout Seal Depth ft D Neat Cement (94 /b bag/S-10 gal water) ❑ Sand Cement sack mixff gal water <br />❑ Bentonite (20% solids) D Other /1UG 2022 <br />Grout Placement Method ❑ Pumped ❑ Free Fall 11 Other [I Retardant / Accelerator (name) <br />PEDESTAL Installed By D Driller ❑ Pump Contractor ❑ Other vrinNMFNAL <br />❑ Concrete Pedestal ❑Dimensions: Width ft Length ft Thick HFAi TI -i ENViRQNN1FNTAL <br />in ❑ Christy Box ❑ Stove Pipe <br />PUMP Submersible❑ Turbine ❑ Other HP,' -LOP' Pump Setl�� ft Standing Water Level ��fl 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 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 />iRED FOR 1`;'SPF-C 1'10-,iS - ?LY..SE tali. (=99) 95, -^76, <br />�j / DEPARTMENT USE ONLY <br />Application Accepted By_iG- L__ Date�pZ Area (lam Employee ID#fiq_� <br />Grout Inspection By C` Date ❑ SPECIAL Well Permit <br />Pump Inspection By77 G� Date ❑ WAIVER Received <br />Soil Boring Inspection By Date g Constructed Well Depth ft <br />COMMENTS yei)Cv Be 11 Am,-ei--, CG fkzit �kS In i111/ i7i.r/1Ern.J� V%AtAprirA(c r+../r.ro etye/r <br />T <br />m <br />D <br />v <br />v <br />m <br />to <br />PE <br />Codes <br />SC Received <br />Info <br />Check#/ Amount D to Permit/ Invoice Well lDn <br />Cash Remitted Service Re uest <br />381 <br />Dso <br />477 3 <br />EIin043-05 1012512021 Page I oft Well / Pump Permit <br />LUrI� 4� lUGc'� <br />