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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 CALL 12nQ1I 9RA-7907 cno 1.gpp,T,L• tcvmlmrn • <br />- -- --- ^� • ,,• • • •••• •••, •_•• I-- H-Ar1F`Q0' t i MAK t-KUM DATE ISSUED <br />cnuwruo tnu.rsuLl <br />% L / <br />JOBADDRESs 280 N Dietrich Rd CITYZP Linden, CA 95236 <br />CROSS STREET Eastern 14 i ,; R d APN 10522030 PARCEL SIZE 1- 4 8 LAND USE APPLICATION # <br />OWNERNAME Greg Podesta PHONE 209 887 2925 <br />OWNER ADDRESS 280 N D i p t r i rh Rd CITY/STATEIZIP <br />CONTRACTOR Purviance Drillers, Inc PHONE209-887-3554 <br />CONTRACTORADDRESPO Box 64 Linden, CA 95236 <br />CITYISTATE/ZIP <br />SUBCONTRACTOR n/a <br />PHONE <br />SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br />LICENSE XXC-57 ❑ C-61 ❑ D-09 7 Other NUMBER 377923 EXPIRATION DATE 7/31 /23 <br />DOMESTIC WELL SAMPUNG: " General Mineral/Coliform Bacteria (4391) = Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE omestic/Private ❑ 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 ❑ NBW Well❑Replacement Well ❑Well Alteration/Modification ❑Other <br />❑ Monitoring WeU(s) # of wells ❑ Soil Borings) # of borings ❑ Geotechnical ° <br />Out <br />❑ -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair APR <br />❑ New Pump KPumpReplacement ❑ Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION N Oq <br />INEe <br />Drilling Method ElMud Rotary ❑ Air Rotary ❑ Auger D Cable Tool C1Push Point IJOther N� O , co( <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size D_��6t r <br />❑ Conductor Casing in diameter I Conductor �EIVT <br />Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth ft ❑ Neat Cement (94 lb bag15-10 gal water) ❑ Sand Cement sack mixl7 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other D Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal ❑Dimensions: Width ft Length ft Thick <br />in ❑ Christy Box ❑ Stove Pipe <br />PUMP ubmersibleD Turbine ❑ Other HP ( Pump Set ft Standing Water Level t 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 />t11N1111 !1 24 1I')? F. +:D% >9t '' Nol'1( 1.111.;)1 1j,,1-. I,, I ,)I; <br />DEPARTMENT USE ONLY <br />L/ <br />Application Accepted By Date y �/ �..� Area 7 % C`r <br />Employee ID# >�S <br />Grout Inspection By _ ate ❑ SPECIAL Well Permit <br />Pump Inspection By ?/, _�Ll f 7 -7 W 14i4i Date Z L ❑ WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />PE SC Received Check#/ Amount permit/ <br />Codes Info Cash Remitted Date Service Re uest # Invoice # <br />Well ID# <br />L43� OBJ Ser-- 2 Z <br />Page i af2 Well / Pump Permit <br />rn <br />1 <br />m <br />D <br />v <br />0 <br />m <br />N <br />rn <br />