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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 />IV VIv-KEFUNDABLE rERMIT GALL (LUy)yb3-Tb9f FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 5721 Cox Rd CITY/ZIPLj nr1An, CA 957.36 <br />CROSS STREET Baker Rd APN09128018 PARCEL SIZE 11 .98LANDUSE APPLICATION # <br />OWNERNAMEVince Belli PHONF209 639 2345 <br />OWNERADDRESS 5721 Cox Rd CITY/STATE/ZIPLinden, CA 95236 <br />CONTRACTOR Pu_rviance 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 IXC -57 ❑ C-61 ❑ D-09 ❑ Other <br />CITYISTATEIZIP <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 )DomestictPrivate rJ 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 AlterationlModification CI Other PA V. _ <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) 9 of borings ❑ Geotechnical N <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair `/L: rl <br />0 New Pum Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION SA <br />Drilling Method ❑Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other N J <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Graj i V/ R r <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft DEP NTq L <br />E <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched E. Steel ❑ Plastic 11 Stainless Steel EI Other QRTMENT <br />Grout Seal Depth ft ❑ Neat Cement (94 lb bag/5-90 gal water) ❑ Sand Cement sack mix17 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />P Concrete Pedestal ❑Dimensions: Width ft Length ft Thick <br />�in ❑ Christy Box ❑ Stove Pipe <br />PUMP `F�Submersible❑ Turbine ❑ Other HP l Pump Set_L6- (i J 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 />.1II\INI M 24 HOUR ADN'A\CE NOTICE: REQUIRED FOR I\ ,PECTIo\s - PLEASE CALL (209) 9i3-7697 <br />DEPARTMENT USE ONLY <br />Application Accepted By /r— z'Date 7 oZ Area Cie Employee ID# FfCtdl kGrout Inspection By _ _ Date ❑ SPECIAL Well Permit <br />Pump Inspection By� Date ❑ WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS /-L 50 104(-d vJ) t1i e&,�X . Daci,m Pn4 GcuEG/j r►e; tFs f, we <br />PE Sc Received <br />Codes Info B <br />Check#/ Amount Permit/ <br />Cash Remitted Date Service Re uest # Invoice # Well ID# <br />477 U4&4 N <br />`. <br />EHD043-06 10/25/2021(�� Page I ort Well /Pump Permit <br />/Ysg3S.2�3� <br />