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r <br />1 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 ZU9 953-7697 FOR INSPECTIONS hXPIKES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 7425 Fine Rd CITY/zIP Linden, CA 95236 <br />CROSS STREET Comstock Rd APN 09133005 PARCEL SizE3 3 . 1 1 LAND USE APPLICATION # <br />OWNER NAME R. J COstigliolo PHONE209 351 0078 <br />OWNER ADDRESS 7300 N Fine Rd CITY/STATE/ZIP Lln u,CA 95,236 <br />CONTRACTOR Purviance Drillers, INC PHONE 209 887 3554 <br />CONTRACTOR ADDRESS P . O . BOX 64 CITY/STATE/ZIP Linden , CA 95236 <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE 2 C-57 ❑ C-61 ❑ D-09 ❑ Other <br />CITYISTATE/ZIP <br />NUMBER 3 7 7 9 2 3 EXPIRATION DAT <br />DOMESTIC WELL SAMPUNc: ! General Mineral/Coliform Bacteria (4391) = Dibromochloropropane (4392) ..Arsenic (4393) <br />INTENDED USE '*DomestirJPrivate ❑ 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 <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings ❑ GeotechnicalNEC <br />'I'g�C <br />❑ Out -Of -Service Well 13 Out -Of -Service Well Renewal ❑ Cross -Connection Repair ~ r V C D <br />❑ New Pump Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION14 ZUZ2 <br />Drilling Method ❑ Mud Rotary F1 Air Rotary ❑ Auger El Cable Tool [I Push Point ❑ Other SAN JOA <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/G6*4 "ON)`L I�riieter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft ARTfOEN7- <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth ft ❑ Neat Cement (94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix17 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped U Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal ❑Dimensions: Width ft Length ft Thick <br />in ❑Christy Box ❑ Stove Pipe <br />PUMP Submersible❑ Turbine ❑ Other HP 1 2- Pump Set QPL ft Standing Water Level ft <br />Plot Plan Req irements: 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 />Al'i 120%j; <br />DEPARTMENT USE ONLY <br />Application Accepted By — l� x Date " � Area y %(� Employee ID# <br />Grout Inspection By 4 Date ❑ SPECIAL Well Permit <br />Pump Inspection By %_ ! Date ❑ WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS 3,>-1 -1 L1, 05-0.46ov , <br />'rt <br />M <br />D <br />0 <br />0 <br />m <br />m <br />L <br />PE SC Received Check#/ Amount Dat Permit/ <br />Codes Info 5M Cash Remitted Service Reguest # <br />Invoice # <br />Well ID# <br />e--- / i 12 22 <br />EfiDO'13-N, I0R5I2021 Page t 0f3 Nell lPump Pertnit <br />1 <br />137za752_3 <br />