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I <br />1 WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />.A. -..A — ------ - __ — <br />A �cr�tvvnolc r�ttivu l GALL (ZU9) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />Joe ADDRESS 9947 S Temple Creek Rd cls./zIP Escalon,CA 95320 <br />CROSS STREET S k i f -F Rd APN 20519042 PARCEL SIZES • 8 8 LAND USE APPLICATION # <br />OWNER NAME Lance IOppini PHONE209 531 7879 <br />OWNER ADDRESS PO BOX 1229 <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 Ripon , CA 95336 <br />PHONE209-887-3554 <br />CITY/STATEIZfP Linden, CA 95236 <br />PHONE <br />CITY/STATEIZIP <br />❑ Other NUMBER 3 7 7 9 2 3 EXPIRATION DATE 7 13 1 X 2 3 <br />LIOMESTIC WELL SAMPLING: h General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) 7 Arsenic (4393) <br />­11u5uvrnvaie u 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 ❑ Geotechnical <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Reoair <br /># of borings <br />u t�ew rum u rum Ke lacement Pum Re air rrirc.0 ❑ Raise Well Casin <br />WELL CONSTRUCTION <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ 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 gYMENT <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched n Steel ❑ Plastic ❑ Stainless Stee M@NED <br />Grout Seal Depth ft ❑ Neat Cement (94 lb bag/5-10 gal water) ❑ Sand Cement sa /7 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped ❑ Free Fail ❑ Other ❑ Retardant / Accelerator (name) <br />- <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other T"" PARlrAENi <br />❑ Concrete Pedestal ❑Dimensions: Width It Length ft Thick <br />in ❑ Christy Box Li Stove Pipe <br />PUMP ❑ Submersiblej( Turbine ❑Other HP Pump Set J--&) ft Standing Water Level /37 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 />111 r!) FF 11H INti 117'11'111�^�_ <br />DEPARTMENT USE ONLY <br />Application Accepted By l� /4-- Z_ L Date q,q (c. b dC <br />Area Employee ID# A (7 <br />Grout Inspection By Date 0 SPECIAL Well Permit <br />Pump Inspection By Date_ Z � Z4 22 0 WAIVER Received <br />Soil Boring/Inspection By Date Constructed Well Depth ft <br />COMMENTS LA G_l 1 Xv-0 <br />PE SC Received Check#/ Amount <br />Codes Info Gash Remitted Date <br />q3$ 6 1 6- 477 t •Z , r <br />Permit/ <br />S ice e e Invoice # <br />k* <br />Well ID# <br />- <br />FFrII(41:dX Inl�cnMi / / <br />C ( lPoft <br />4 (� Well I Pump Permit <br />