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1 WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />rwly-rterulvuAbLt rtKMIT (.:ALL (ZUU) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOBADDRESS 20262 Wal nut- Dr CITY/ZIP Linden, CA 95236 <br />CROSS STREET Wall Rd APNO 91 3 0 0 0 2 PARCEL SIZE <br />1 9 • 5 7 LAND USE APPLICATION # <br />OWNER NAME Ej 1 Prs Ran ch PHONE <br />OWNER ADDRESS P_ n_ BOX 1048 <br />CONTRACTOR Purviance Drillers, Inc <br />PO Box 64 <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR n/a <br />SUBCONTRACTOR ADDRESS <br />LICENSE �g -57 ❑ C-61 U D-09 ❑ Other <br />CITY/STATE/ZIPLinden,CA 95236 <br />PHONE209-887-3554 <br />CITYISTATEIZIP Linden, CA 95236 <br />PHONE <br />CITYISTATEIZIP <br />NUMBER 3 7 7 9 2 3 EXPIRATION DATE 7/ 31 / 2 3 <br />DOMESTIC WELL SAMPLING: `- General Mineral/Coliform Bacteria (4391) _ Dibromochloropropane (4392) ::-i Arsenic (4393) <br />INTENDED USE U Uomestic/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 Q w <br />TYPE OF WORK <br />❑ New Well D Replacement Well ❑ Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings ❑ Geotechnical <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />❑ New Pump )!Lpump Replacement ❑ Pump Repair ❑ Raise Well Casino <br />sar w�ys/ <br />J�� Q <br />WELL CONSTRUCTION 4 AfJ <br />Drilling Method _—Mud Rotary El Air Rotary ❑ Auger r1 Cable Tool ❑ Push Point D Other ENV/OAQVIN <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size �t~n.ENrT �Cer <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft 'YRWAIT <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched D Steel ❑ Plastic 11 Stainless Steel ❑ Other <br />Grout Seat Depth ft ❑ Neat Cement (94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br />❑ Bentonite (20% solids) D Other <br />Grout Placement Method U Pumped ❑ Free Fall ❑ Other ❑ Retardant /Accelerator (name) <br />rnueslAl Insianeo by U Urlller ❑ Pump Contractor ❑ Other <br />Concrete Pedestal ❑Dimensions: Width ft Length ft Thick <br />in C Christy Box ❑ Stove Pipe <br />PUMP Submersible❑ Turbine ❑ Other HP Pump Set ft Standing Water Level <br />Plot Plan Re uirements: 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 />MINENICsi 231 OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PI..h:ASE CALL (209) 9i3-7697 <br />DEPARTMENT USE ONLY <br />Application Accepted By l' Date.+�07 Area Employee ID# Ffeyk <br />Grout Inspection By Date ❑ SPECIAL Well Permit <br />Pump Inspection By L Date ❑ WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS �al� t'fP,✓Il� ren rofir e, eS _15 �I <br />PE SC Received Check#/ <br />Codes Info B Cash <br />Amount Date Permit/ Well ID# <br />Invoice # <br />Remitted Service Request # <br />3%) OHO.477 <br />ltq 121 <br />EH0043-06 1012512021 Page 1 of Well I Pump Permit <br />