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f - WELL/PUMP PERMIT <br />JAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN-KEFUNDABLE HERMIT GALL (LUy) U0.5 -110y1 FUK INSI'tc I IUNs t=ArR[GJ 1 7 tHK r KVIVI VH I C IJJUCU <br />JOB ADDRESS 7505 N Podesta Ln CITY/ZIP Linden, CA 95236_ <br />CROSS STREET Podesta Ln APN 0 91 43003 PARCEL SIZE 10 3 - UND USE APPLICATION # <br />OWNER NAME B&B Ranch <br />OWNER ADDRESS 7507 N Podesta Ln CITY/STATE/ZIP Linden, CA 95236 <br />CONTRACTOR Purviance 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 XXC-57 ❑ C-61 ❑ D-09 ❑ Other <br />CITY/STATE/ZIP <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 ❑ Domestic/Private Irrigation/Agricultural ❑ Industrial C Water Quality Monitoring `_I 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 0 Replacement Well ❑ Well Alteration/Modification [I Other _& <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings C Geotechnical ° b / V� <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair 400 O <br />❑ New Pump ❑ Pump Replacement Pump Repair ❑ Raise Well Casing S ✓/0 U �J] <br />WELL CONSTRUCTION f <br />FNVIAQ J/N <br />Drilling Method ❑ Mud Rotary L Air Rotary (IAuger n Cable Tool [IPush Point ❑ Other E R ^C/T <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size DF MV�Ieeier <br />❑ Conductor Casing in diameter 1 Conductor Casing Depth ftT�1F/�T <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth ft ❑ Neat Cement (94 lb bag/5-10 gal water) ❑ Sand Cement sack mix17 gal water <br />L Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal ❑Dimensions: Width ft Length ft Thick <br />lin ❑ ,Christy Box ❑ Stove Pipe <br />PUMP Y Submersible❑ Turbine ❑ Other HPI ) Pump Seth ft Standing Water Level l—1 ", ;I'' ft <br />Plot Plan RegUirements: 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 />DEPARTMENT USE ONLY )l',, <br />p– <./ c� Employee lD# �C t � K <br />Application Accepted By Date � ! Area <br />Grout Inspection By 4 d Date Ll SPECIAL Well Permit <br />Pump Inspection By Date �-� Q WAIVER Received <br />Soil Boring Inspection By LDate Copstructed WeIII De ft <br />COMMENTS ll?6 : E'S 'J we- I % <br />rn <br />m <br />D <br />v <br />v <br />m <br />m <br />Cn <br />rn <br />PE <br />Codes <br />SC Received Check#/ <br />Info B Cash <br />Amount DatePermit/ Invoice # Well ID# <br />Remitted Serv'ce Re uest # <br />060— <br />47-1 <br />EHDO43-06 10I25i2021 &W <br />Pagc I of 2 Well ! Pump Pcrmit <br />