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1 WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN-MizFUNDABLE PERMIT LoALL (ZUU) y5S-76y! FOR INSPECTIONS tAI'IKt5 'I YEAR FROM LJATE ISSUED <br />JOB ADDRESS 12901 E Eight Mile Rd CITY/ZIP Stockton,CA 95215 <br />CROSS STREET Jacktone Rd APN 0632001 1 PARCEL SIZE 28.6 LAND USE APPLICATION'ir <br />OWNERNAME Tom Sanguinetti PHONE <br />OWNERADDRESS 1410 Elkhorn Dr CITY/STATE/ZIP � Stockton CA 95209 <br />CONTRACTOR Purviance Drillers, Inc <br />PO Box 64 <br />CONTRACTOR ADDRESS <br />n/a <br />ADDRESS <br />LICENSE �C-57 ❑ C-61 ❑ D-09 ❑ Other <br />PHONE209-887-3554 <br />CITYISTATE/ZIP Linden, CA 95236 <br />CITYISTATE/ZIP <br />NUMBER 377923 EXPIRATION DATE 7/ 31 / 2 3 <br />DOMESTIC WELL SAMPLING: _ General Mineral/Coliform Bacteria (439 1) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE ❑ Domestic/Private Y Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br />❑ Public Water Syst <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 />Permit/ <br />Service Request # Invoice # Well ID# <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings ❑ Geotechnical <br />�,r <br />l�iin_gs <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />R <br />❑ New Pump ❑ Pump Replacement XP_ um Re air ❑ Raise Well Casing <br />�j�� <br />WELL CONSTRUCTION <br />At. <br />� <br />S`rFn <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger i, Cable Tool [I Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Grave <br />s4� i eter <br />❑ Conductor Casing in diameter I Conductor Casing Depth ft HEA N1,/ 0 0/,V <br />NME <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel P. Plastic ❑ Stainless Steel <br />Grout Seal Depth ft ❑ Neat Cement (94 /b bag/5-10 gal water) ❑ Sand Cement <br />Sack I water <br />❑ Bentonite (20% solids) ❑ Other <br />j <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL tnstalled By ❑ Driller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal ❑Dimensions: Width ft Length ft Thick <br />lin ❑ Christy Box ❑ Stove Pipe <br />PUMP ❑ Submersible' ❑ Other HP Pump Set V` 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 200' radius of proposed well. <br />DEPARTMENT USE ONLY <br />Application Accepted By Date R /74 <br />Grout Inspection By A I Date <br />Pump Inspection By ) Date I ✓ l Z �-� <br />Soil Boring Inspection By Date <br />COMMENTS <br />a i <br />Area I Employee IDaf�q <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth ft <br />3S•o(')0v •LlI,1i qco <br />N <br />M <br />D <br />0 <br />0 <br />m <br />C" <br />PE Sc Received Check#/ Amount <br />Cash itted Date <br />Codes Info B em <br />Permit/ <br />Service Request # Invoice # Well ID# <br />050 aL V11,Sa_ 2 <br />�I <br />E'ru,W3-L'<i 70.?'{2031 Pam I ort <br />\Nell / Pump Permit <br />