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WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 INUIy-KtFUNUABLE t F=RMIT CALL (ZWJ) y53-1bU7 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS 8241 N Tullv Rd CITY/zIP Linden, CA 95236 CROSS STREET Eight Mile Rd APN 09108016 PARCEL SIZE 4 0 . 0 LAND USE APPLICATION OWNERNAME Lawrence Samhado PHONE OWNER ADDRESS P.O. BOX 461 CITYISTATE/ZIPL i nd en , CA 95236 CONTRACTOR Purviance Drillers, Inc PHONE209-887-3554 PO CONTRACTOR ADDRESS Box 64 Linden, CA 95236 CITYISTATE/ZIP SUBCONTRACTOR n/a SUBCONTRACTOR ADDRESS LICENSE X-2XC-57 C C-61 D D-09 D Other PHONE CITYISTATEIZIP NUMBER 3 7 7 9 2 3 EXPIRATION DATE 7/ 31 / 2 3 DOMESTIC WELL SAMPLING: = General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) - Arsenic (4393) INTENDED USE ❑ Domestic/PrivateIrrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil SamplinglCharacterization D Public Water Syst m If di;ierenl from Ovmer: Water System Name Contact Name or Phone Number TYPE OF WORK C New Well i; Replacement Well C Well Alteration/Modification D Other D Monitoring Well(s) o. wells E. Soil Borings) # of borings 0 Geotechnical ❑ Out -Of -Service Well ❑ Out -O. -Service Well Renewal D Cross -Connection Repair E New Pump D Pump Replacement VPUmo Repair D Raise Well Casino 9•J WELL CONSTRUCTION " Drilling Method = Mud Rotary ❑ Air Rotary U Auger Cable Tool D Push Point ❑ Other SANjOQQUIN Proposed Well Depth ft Excavation in diameter CU Open Bottom D Gravel Pack/GraveY&M TLj 18is peter C Conductor Casing in diameter I Conductor Casing Depth 1l NT Well Casing Diameter in Thickness/Gauge/ASTM Sched D Steel 0 Plastic Cl Stainless Steel D Other Grout Seal Depth ft -! Neat Cement (94 lb bag/5-10 gal vlater) ❑ Sand Cement sack mixt gal water Bentonite (20% solids) Ei Other Grout Placement Method ❑ Pumped G Free Fall n Other D Retardant / Accelerator (name) PEDESTAL installed By ❑ Driller u Pump Contractor ❑ Other D Concrete Pedestal ❑Dimensions: Width ft Length It Thick �in D Christy Box ❑ Stove Pipe PUMP ❑ Submersible'!�_Turbine ❑ Other HP I!i 1, ) Pump Set I�tJ ft Standing Water Level !. i t Plot Plan Requirements: Attach . a plot plan with the exact location of water well with respect to the following items: CPS Coordinates, property lines, adjoining properties, water bodies or courses, drainage pattern, roads, existing wells, structures, potential sources of contamination, sewers or private disposal systems. Include distance from two property lines. For Domestic, Agriculture, Industrial well, provide location of any water wells or surface water within 200' radius of proposed well. -� � �%�DEPARTMENTrUSE ONLY Application Accepted By -- 7 "' ''\ Date 6�q /7 Z Grout Inspection By 4 Date Pump Inspection ByZIL � Date Z� Soil Boring Inspection By Date COMMENTS T7 'S : t✓ Area Employee ID: SPECIAL Well Permit 0 WAIVER Received Constructed Well Depth ft PE SC Received Check#! I Amount Date Permit/ Invoice ; Well ID# Codes Info By Cash Remitted Service Request 9 I I 1 T i II I I I I I I i i EHDO?3-05 10i25Q021 P e I ort Neil i Pump Permit