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r <br />1 WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE -STOCKTON CA 95205 - (209) 468-3420 <br />Itl VIV-Rtf-VNUAtiLt t'tKM1I I.ALL ZUy U0J-!bVf FOR INSPECTIONS to IKtS 7 YEAR FROM DATE ISSUED <br />JOBAODRESS 15850 N Tully Rd CITY/zIP Lodi,CA 95240 <br />CROSS STREET Smith RD APN 0 5 31 1 0 0 7 PARCEL SIZE R 5 '� LAND USE APPLICATION # <br />j� <br />OWNER NAME Tri G — V ;1" 7 LZ �I tr Y S PHONE <br />OWNERADDRESS 9189 N Ashley Ln CITY/STATE/ZIP Stockton, CA 95212 <br />CONTRACTOR Purviance Drillers, Inc <br />PO Box 64 <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR n/a <br />SUBCONTRACTOR ADDRESS <br />LICENSE �QC 57 G C-61 0 D-09 ❑ Other <br />PHONE209-887-3554 <br />CITY/STATE/ZfP Linden, CA 95236 <br />CITY/STATE/ZIP <br />NUMBER 3 7 7 9 2 3 EXPIRATION DATE 7/ 31 / 2 3 <br />DOMESTIC WELL SAMPLING: = General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) = Arsenic (4393) <br />INTENDED USEDomestic/Private ❑ Irrigation/Agricultural ❑ Industrial ElWater Quality Monitoring ❑ Soil Sampling/Characterization <br />tuPublic Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK ❑ New Well ❑ Replacement Well C Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings ❑ Geotechnical $ of borings <br />❑ Out -Of -Service Well C Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />❑ New Pump `Pump Replacement C Pump Repair ❑ Raise Well Casino <br />Drilling Method r- Mud Rotary ❑ Air Rotary ❑ Auger Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth It Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br />I; Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched 11Steel ❑ Plastic ❑ Stainless Steel 7 <br />Grout Seal Depth ft ❑ Neat Cement (94 Ib bag/5-10 gal water) ❑ Sand Cement I r gal water <br />C Bentonite (20% solids) u Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant I Accelerator (name) I I I i "1 I em vt <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other ,e,,,• eee+arv, <br />❑ Concrete Pedestal ❑Dimensions: Width ft Length ft Thick :vn:oNr ^iTAL <br />in ❑ Christy Box 0 Stove Pipe RTMENk <br />PUMP `t SubmersibleD Turbine ❑ Other HP - Pump Set–!—q 10ft 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 200' radius of proposed well. <br />:�:? t{' ..'_3�' `.,;i•r :STiCf; iZ:a?I'.I?:?% i'isii 1titiF' a`i'l) <ti-:'l.:i`,S L . :... ('-�`-;1 ti5�= <br />DEPARTMENT USE ONLY <br />Application Accepted ByDate 7j Area C l Employee ID# <br />Grout Inspection By Date 1 C, SPECIAL Well Permit <br />Pump Inspection By Date l " \ 0 WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />tZ) �.ZVC .,lZ ) i <br />m <br />D <br />0 <br />0 <br />M <br />M <br />N <br />PE <br />Codes <br />Sc Received Check#/ <br />Info s <br />Amount atPermit/I Invoice # Well ID# <br />Remitted Service Request 4 <br />N 31 i <br />0" "7 <br />�7 I `' <br />_ <br />- - <br />i <br />I <br />EliD0.3-05 In5127031 / LLJO 6 1_� -,t& lj __.r/l a/ � Pagc I ort lVell /PUMP Pemir <br />