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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 />NON-REFUNDABLE PERMIT GALL (ZUy) y53 -/by! 1 -VK INbVtcl IUNs <br />JOB ADDRESS <br />CROSS STREET _ <br />OWNER NAME <br />OWNER ADDRESS <br />CAr 1 r-1 CMr-1 rrtVM —nI G Nom]. <br />8444 N Pezzi Rd CfTY/zIP Stockton, CA 95215 <br />Comstock Rd APN 08904025 PARCEL SIZE 9 - 59 LAND USE APPLICATION <br />i <br />Podesta Bros PHONE <br />8000 N Podesta <br />CONTRACTOR Purviance <br />PO Box <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR n/ a <br />SUBCONTRACTOR ADDRESS <br />Rd CITY/STATE/zpLinden, CA 95236;'/ <br />Drillers, Inc PHONE209-88'7-554 <br />64 CITY/STATE/ZIP Linden, CA 95236 <br />LICENSE ) C-57 ❑ C-61 ❑ D-09 ❑ Other <br />CITY/STATE/ZIP <br />NUMBER 377 923 EXPIRATION DATE 7/ 31 / 2 3 <br />nnMFs-nc WELL SAMPLING: -General Mineral/Coliform Bacteria (4391)((' Dibromochloropropane (4392) -.Arsenic (4393) <br />INTENDED USE❑ ornestic/Private [IIrrigation/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 C 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 Pum um Replacement ❑ Pum Repair ❑ 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 PAYMENT <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑'6t <br />Grout Seal Depth ft ❑ Neat Cement (94 lb bag/5-10 gal water) ❑ Sand Cement �a IX17 gal water <br />❑ Bentonite (20% solids) ❑ Other 2077 <br />Grout Placement Method ❑ Pumped ❑ Free Fall [I Other ❑ Retardant / Accelerator (name) <br />LNVIRONMcurn.. <br />PEDESTAL Installed By D Driller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal ❑Dimensions: Width ft Length ft Thick <br />in ❑ Christy Box ❑ Stove Pipe <br />PUMP ubmersible❑ Turbine ❑Other HP '� Pump Set ft Standing Water Level 1 ` l� ft <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 />DEPARTMENT USE ONLY L� G 1j <br />Application Accepted By Date 9 $ d� Area / �-/ Employee ID# r!1 h F� <br />Grout 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 <br />PE <br />Codes <br />`i38) <br />SC Received <br />Info 8M 11 <br />bSo <br />Check#/ Amount Date Permit/ Invoice # Well ID# <br />1 )CAshA Remitted Urvice Re uest # . <br />4`77 <br />EM043-06 10125/2021 lLl � 11,,40 7 e 7 Y/2-V�°xr2/ ••�•,, •�•••�•�•�.,• <br />