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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 />NUN-KEFUNDABLE PERMIT GALL (209) 953-7697 FOR INSPECTIONS <br />EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 1349 S Drais Rd <br />CITY/ZIP <br />Linden,CA 95215 <br />CROSS STREET Copperopo l i s Rd APN 1 8 3 21 0 0 8 <br />PARCEL SIZE 10 <br />LAND USE APPLICATION # <br />OWNER NAME .Ta 1 me Romero <br />PHONE <br />OWNER ADDRESS 1349 Drais Rd <br />CITY/STATE/ZIP <br />Linden,CA 95215 <br />CONTRACTOR Purviance Drillers, Inc <br />PHONE209-887-3554 <br />PO Box 64 <br />Linden, CA 95236 <br />CONTRACTOR ADDRESS <br />CITY/STATE/ZIP <br />SUBCONTRACTOR n / a <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />CITY/STATEIZIP <br />LICENSE X)} C-57 ❑ C-61 ❑ D-09 ❑ Other <br />NUMBER 377923 <br />EXPIRATION DATE 7 / 31 / 2 3 <br />DOMESTIC WELL SAMPLING: - General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) .- Arsenic (4393) <br />INTENDED USE ❑ Domestic/Private 171 Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring D 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 ❑ Well Alteration/Modification ❑ Other 11.4 <br />❑ Monitoring Well(s) # of wells 17 Soil Boring(s) # of borings ❑ Geotechnical/ <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair VES <br />❑ New Pump ❑ Pump Replacement X Pump Repair ❑ Raise Well Casing Aa ., <br />WELL CONSTRUCTION SqN 0 c L 2022 <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary N Auger n Cable Tool 11Push Point n Other E <br />A <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Grave L_4 „ NP14 ' <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft gRT/Y ANT <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched : Steel ❑ Plastic ❑ Stainless Steel it Other <br />Grout Seal Depth ft ❑ Neat Cement (94 lb bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method E Pumped ❑ Free Fall 11 Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By C Driller ❑ Pump Contractor Other <br />❑ Concrete Pedestal ❑Dimensions: Width ft Length ft Thick Iin 11 Christy Box Stove Pipe <br />PUMP ❑ SubmersibleC Turbine ❑ Other HP 's !� Pump Set i ft Standing Water Level '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 ONLY <br />din ill <br />Application Accepted By �f ' ��L Date `/"i ✓�� Area Employee ID# ,All <br />1 C <br />Grout Inspection By -- PJate ❑ SPECIAL Well Permit <br />Pump Inspection By Date Z2 U WAIVER Received <br />Soil Boring Inspection By Dat Constructed Well Depth ft <br />COMMENTS DQ, ; C I)`'.Cr S <br />rn <br />D <br />0 <br />0 <br />m <br />m <br />rn <br />rn <br />PE <br />Codes <br />SC Received Check#/ Amount ate Permit/ Invoice # Well ID# <br />Info By Cash Remitted Se ice Rkeqyest# <br />� 477-- -' <br />EHDCw3-06 !025/2021 Pale 1 ur2 \Nell /Pua:p Permit <br />