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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 />tVUIV-I[trUIVUAt3LL rLRMIT [:ALL (ZU9) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOBADDRESs 5522 Harrison St C,Ty/zp Linden,CA 95236 <br />CROSS STREET Monte Vista Dr APN 091 28043 PARCEL SIZE 1 .78 LAND USE APPLICATION #F <br />OWNERNAME CaA:h.grjp(A larc)Arr3lI i PHONE <br />OWNERADDRESS 5522 Harrison St <br />CONTRACTOR Purviance Drillers, Inc <br />PO Box 64 <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR n/a <br />SUBCONTRACTOR ADDRESS <br />LICENSE �C-57 ❑ C-61 ❑ D-09 <br />CITY/STATE/ZIP Linden, CA 95236 <br />PHONE209-887-3554 <br />CITY/STATE/ZIP Linden, CA 95236 <br />PHONE <br />CITY/STATEIZIP <br />❑ Other NUMBER 3 77923 EXPIRATION DATE 7/ 31 /23 <br />DOMESTIC WELL SAMPLING: = General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) = Arsenic (4393) <br />INTENDED USE ❑ Domestic/Private X, rrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Ovmer: 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 ❑ Geotechnical # of borings <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />❑ New Pump 4 Pump Replacement ❑ Pump Repair ❑ Raise Well Casinq <br />WELL CONSTRUCTION <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger C Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic U Stainless Steel ❑ Other <br />Grout Seal Depth ft ❑ Neat Cement (94 lb bag/5-10 gal water) ❑ Sand Cement PAj (W gal water <br />❑ Bentonite (20% solids) ❑ OtherRECEIVED <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) ... _ _ _ <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor = Other — I. <br />❑ Concrete Pedestal ❑Dimensions: Width ft Length ft Thick SAN JOAou <br />�in ❑ Christy Box ❑ Stove Pipe ENVIRONMENTAL <br />PUMP Submersibi? %Turbine ❑ Other HP Pump Set ft Standing Water Level ft <br />Plot Plan Requirements: ALtach,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 `eater wells or surface water within 200' radius of proposed Nveil_ <br />OI'It.ii;V, N' C-1 N01" C IL P% E, t?? 1) t -0R INS11F('I I')", S - PIL - %SFr ; - 2 0 t• <br />DEPARTMENT USE ONLY <br />Application Accepted By XPi-� ' L_ Date 7/VT� Area �Z _ Employee ID# F_,r'sI1/Z <br />Grout Inspection By A A Date ❑ SPECIAL Well Permit <br />Pump Inspection By Date Z ` Z Z ❑ WAIVER Received <br />Soil Boring Inspection By <br />COMMENTS r()( <br />Date <br />Constructed Well Depth <br />>'3: )-)- 4k I - ( -t I - v9Z`7'L <br />ft <br />TA <br />m <br />D <br />0 <br />0 <br />m <br />PE <br />Codes <br />SC <br />Info <br />Received Check#/ <br />-ABY, Cash <br />Amount Date Permit/Invoice # Well 1D# <br />Remitted Service Re uest# <br />! I I <br />EHDC43-05 (0,15C_!021 / y & g­rg � -c 1 oft Nell /Pump Per,nit <br />