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1 WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN -KF -FUNDABLE HERMIT L;ALL (ZUU) S53-/11Jy/ FOR INSPECTIONS EXPIKE5 9 YEAR FROM UATE ISSUED <br />JOB ADDRESS 1493 S Jacktone Rd CITYIZIPStockton,CA 95215 <br />CROSS STREET ('nlDpp7=r)pn 1 l s Rd APN 1 0323023 PARCEL SIZE 12 , 7 9LAND USE APPLICATION # <br />OWNER NAME R & J Dondero PHONE <br />OWNERADDRESS 20480 E Copperopolis Rd <br />CONTRACTOR Purviance Drillers, Inc <br />PO Box 64 <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR n / a <br />SUBCONTRACTOR ADDRESS <br />LICENSE )O�C-57 n C-61 ❑ D-09 ❑ Other <br />CITYISTATEIZIPLinden, CA 95236 <br />CITY/STATEIZIP <br />CITY/STATE/ZIP <br />PHONE209-887-3554 <br />Linden, CA 95236 <br />PHONE <br />NUMBER 3 7 7 9 2 3 EXPIRATION DATE 7/ 31 / 2 3 <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) . Arsenic (4393) <br />INTENDED USE omestic/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 11 A <br />TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other ' `� ' <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings ❑ Geotechnical of boring <br />❑ Out -Of -Service ell ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair , <br />11 New Pump Pump Replacement ❑ Pump Repair r]Raise Well Casing SAN o 2022 <br />WELL CONSTRUCTION ENV QU/N C <br />Drilling Method n Mud Rotary [73 Air Rotary C Auger n Cable Tool C Push Point n Other HEATH I°Nf''�1ENOUN�T y <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size E " ` r /alete <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth _ ft ❑ Neat Cement (94 lb bagi5-10 gal water) ❑ Sand Cement sack mrx17 gal wate <br />E. Bentonite (20% solids) n Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall Other ❑ Retardant / Accelerator (name) <br />DEDESTAL Installed By n Driller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal ❑Dimensions: Width ft Length ft Thick <br />n ❑ Christy Box ❑ Stove Pipe <br />PUMP KSubmersible❑ Turbine ❑ Other HPC_ Pump Set ft Standing Water Level t %( J 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 />DEPARTMENT USE 9NLY <br />Application Accepted By Date IF '�L 1 Z " <br />Grout Inspection By <br />Pump Inspection By J 1� C� Date <br />Soil Boring Inspection By Date <br />COMMENTS <br />Area C7 / ry Employee ID# <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth <br />ft <br />T <br />m <br />D <br />v <br />a <br />M <br />in <br />W <br />PE SC Received Check#/ <br />Codes Info B Cash <br />Amount Permit/ <br />Remitted Date Service a uest# Invoice# WeIIID# <br />8/ osI V/w <br />2,7 <br />I <br />E14D043-0510.'25l202I ���� /� � I�/ �r l `/��agelof2 Well Pump Permit <br />