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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 />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS <br />CROSS STREET <br />11194 E Finkbohner Rd CITY/ZIPStcc-kfnnXA 99236 <br />Baker Rd APN 10316043 PARCEL SIZE 6 .0 4 LAND USE APPLICATION # <br />OWNER NAME John & Lvn Armanino <br />OWNER ADDRESS P. O. BOX 599 CITY/STATE/ZiP Li nden ., CA 9 R 2 3 h <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 ) . 57 L C-61 C D-09 ❑ Other <br />PHONE <br />CITY/STATE/ZIP <br />NUMBER 377923 EXPIRATION DATE 7/ 31 / 2 3 <br />DOMESTIC WELL SAMPLING: -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 Owner. Water System Name Contact Name or Phone Number <br />TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other PA V <br />C Monitoring Well(s) # of wells ❑ Soil Boring(s) K of borings ❑ Geotechnicali ` r11Out-Of-Service Well Ll Out -Of -Service Well Renewal C Cross -Connection Repair-�£ElVFn <br />❑ New Pump ❑ Pump Replacement KPump Repair E Raise Well Casing <br />WELL CONSTRUCTION 2t?�z <br />Drilling Method 1-1 Mud Rotary Air Rotary Auger n Cable Tool ❑ Push Point ❑ Other SAN IC <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/ rl�$ix N Ceter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft LTH DEEP " 7A <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched C Steel ❑ Plastic ❑ Stainless Steel Other RT/'SENT <br />Grout Seat Depth ft ❑ Neat Cement (94 lb bagIS-10 gal water) ❑ Sand Cement sack mix/7 gal water <br />L: Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall 7 Other ❑ Retardant /Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ,. Other <br />❑ Concrete Pedestal CDimensions: Width ft Length ft Thick <br />�in ❑ Christy Box ❑ Stove Pipe <br />PUMP `6(Submersible❑ Turbine ❑ Other HP l I I- Pump Set kV) b ft Standing Water Level 1i!5V -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 />Application Accepted By �—� [�L� Date /�/� �� Area i( Employee ID# //,"L <br />Grout Inspection By Date Ll SPECIAL Well Permit <br />11 // n <br />Pump Inspection By (t l�'lt. li Date r LT C ❑ WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS �Jt.c',+/!PYl rilluf�1rlC4 (S b'�- We <br />T <br />m <br />D <br />G <br />v <br />m <br />m <br />N <br />PE <br />Codes <br />Sc Received Check#! Amount Dat Permit[ Invoice # Well ID# <br />Info By Cash Remitted ServiceRe ues # <br />it[ - <br />I <br />F!HMG43-06 I012R2021 � Pace] oft Wait /Pump Pcfmit <br />�gw "Ls3S J� �3 <br />