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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 />NUN -REFUNDABLE PERMIT GALL JZUU) Ub3-Ybbll FOR INSPECTIONS t7,1`1KtJ 9 YEAR FROM DATE ISSUED <br />JoeADDRESS 1453 S Drais Rd CITY/ZIPLinden,CA 95236 <br />CROSS STREET Coppe ropo 1 i s Rd APN 18321007 PARCEL SIZE 10 • 0 LAND USE APPLICATION # <br />IOWNERNAME Donna Mc Ninch PHONE <br />OWNERADDREss 1453 S Drais Rd CITYISTATHZIPLinden,CA 95236 <br />CONTRACTOR Purviance Drillers, Inc <br />PO Box 64 <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR n / a <br />SUBCONTRACTOR ADDRESS <br />LICENSE j:XC-57 D C-61 ❑ D-09 ❑ Other <br />PHONE209-887-3554 <br />CITY/STATE/ZIP Linden, CA 95236 <br />PHONE <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 omestic1PhV2te ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br />17A 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)# or borings ❑ Geotechnical # of borings <br />❑ Out-Of-ServiTuImp <br />❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />171 New PumReplacement ❑ Pump Repair ❑ Raise Well Casing <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 <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel 171Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth ft ❑ Neat Cement (94 Ib bagl5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL installed By ❑ Driller ❑ Pump Contractor 0 Other <br />❑ Concrete Pedestal ❑Dimensions: Width ft Length ftThick <br />lin ❑ Christy Box ❑ Stove Pipe <br />PUMP Submersible❑ Turbine D Other HP. AJ r Pump Set !L_ ft Standing Water Level 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 240' radius of proposed well. <br />DEPARTMENT USE ONLY <br />Application Accepted By �L L Date as <br />Grout Inspection By Date <br />Pump Inspection By�. \ Date n <br />Soil Boring Inspection By Date <br />COMMENTS <br />Area r Employee ID# <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth ft <br />rf <br />m <br />m <br />0 <br />O <br />O <br />M <br />m <br />Cr <br />in <br />PE SC Received Check#/ <br />Codes Info B Cash <br />Amount Permit/ <br />Remitted Date I Service Re uest# Invoice IID# <br />q3 e <br />Ila"22W COD <br />SER n 262 <br />.2 <br />SAN JOAC UA COUNTY <br />Ei-uDW3-0610.2512021 Page 1 oft \vel/P=p Permit <br />