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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 />NUN-KEFUNDABLE VERMIT GALL (1UU) Ub3-16!J1 FOR INSPECTIONS tA'IKtS 1 YEAR FROM UATE ISSUED <br />JOBADDRES54001 N Duncan RD cITYIZIPLinden,CA 95236 <br />CROSS STREET _ St Rt Hwy 26 APN 10509009 PARCEL SIZE 1. O LAND USE APPLICATION # <br />OWNERNAME Steve Galvin PHONE <br />OWNERADDRESS 5432 Giovanni Ct <br />CONTRACTOR Purviance Drillers, Inc <br />PO Box 64 <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR n/ a <br />SUBCONTRACTOR ADDRESS <br />LICENSE X -XC -57 ❑ C-61 D D-09 ❑ Other <br />CITY/STATEIZIPLinden,CA 95236 <br />PHONE209-887-3554 <br />CITY/STATE/ZIP Linden, CA 95236 <br />PHONE <br />CITY/STATEIZIP <br />NUMBER 3 77923 EXPIRATION DATE 7/ 31 / 2 3 <br />DOMESTIC WELL SAMPLING: 7 General Mineral/Coliform Bacteria (4391) - Dibromochloropropane (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 Ovmer: Water System Name Contact Name or Phone Number <br />TYPE OF WORK 7 New Well F, Replacement Well C Well Alteration/Modification D Other F. r H Y <br />i, Monitoring Well(s) # of wells ❑ Soil Boring(s) of borings ❑ Geotechnical eLZI 9 <br />❑ Out -Of -Service Well Out -Of -Service Well Renewal ❑ Cross -Connection Repair v <br />C New Pump --/—Pump Replacement C Pump Repair ❑ Raise Well Casing Alin i n _ <br />WELL CONSTRUCTION t " r V <br />zuzz <br />Drilling Method C Mud Rotary Air Rotary L' Auger Cable Tool n Push Point ❑ Other SAN JOA <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gri*-i"-ON�M-,,E��jt� eter <br />G Conductor Casing in diameter I Conductor Casing Depth ft " ~t-�TMENT <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched_ ❑ Steel D Plastic U Stainless Steel D Other <br />Grout Seal Depth ft Neat Cement (94 Ib bag/5-10 gat water) ❑ Sand Cement sack mW7 gal water <br />Bentonite (20% solids) _ Other <br />Grout Placement Method U2 Pumped ❑ FreeF211 Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By C Driller ❑ Pump Contractor Other <br />❑ Concrete Pedestal ❑Dimensions: Width ft Length ftThick <br />�in ❑ Christy Box ❑ Stove Pipe <br />PUMP 1; Submersible E, Turbine C Other HPC Pump Set 1 ft Standing Water Level �, 0 k) 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 />:{ 17 ..._._.: i3!...'l!i' ... _ - ...... ...t... i=1)l) _...�_ <br />is J <br />�, DEPARTMENT U E ONLY <br />C?/` <br />Application Accepted By �— Z <br />Date � / <br />Grout Inspection By Date <br />Pump Inspection By�ybSjC`� 6 i Date �l G <br />Soil Boring Inspection By Date <br />COMMENTS <br />Area (/C/ Employee ID# <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth <br />ft <br />Lo <br />m <br />D <br />PE <br />Codes <br />Sc Received <br />Info BV <br />Check#/ Amount Date Permit/ Invoice # I Well IDtt <br />Cash Remitted Service Re uest# <br />- 1- IL I 00 3 <br />I <br />3 - <br />I <br />J <br />� <br />Ei;DO;'.',-OS 10."_�?'021/] Pa_c 1 oft Well i Pump Permit <br />�/���Ij�) /-{//� -/� / y-7S'1Jtb(.'� <br />