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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 (ZUU) Ub3-fbyf FOR INSPECTIONS <br />yz55 . .L,ive uax <br />Jos ADDRESS CITY/ZIP <br />CROSS STREET Hwy 88 <br />OWNERNAME Jan Valinoti <br />OWNER ADDRESS 15401 Jahant RD <br />CONTRACTOR Purviance <br />PO Box <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR n/ a <br />SUBCONTRACTOR ADDRESS <br />CJCYIK=0 "1 T tAK I-KUM UA I t 15SUtU <br />Lodi, CA 95240 <br />APN 06310021 PARCEL SIZE 1 LAND USE APPLICATION # <br />Drillers, Inc <br />64 <br />LICENSE )pAC-57 0 C-61 ❑ D-09 ❑ Other <br />PHONE 209-329-2423 <br />CITYISTATE/ZIP Acampo, CA 95220 <br />PHONE209-887-3554 <br />CITYISTATE/ZIP Linden, CA 95236 <br />PHONE <br />CITY/STATE/ZIP <br />NUMBER 377923 EXPIRATION DATE 7/31 /23 <br />DOMESTIC WELL SAMPLING: = General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392)'= Arsenic (4393) <br />INTENDED USE Domestic/Private ❑ Irrigation/Agricultural 0 Industrial 0 Water Quality Monitoring ❑ Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Otivner. Water System Name Contact Name or Phone Number <br />TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Aiteration/Modification 0 Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings ❑ Geotechnical ri <br />0 Out -Of -Service ;Lmp <br />❑ Out -Of -Service Well Renewal 0 Cross -Connection Repair C�/ I N <br />0 New Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION . LJL <br />Drilling Method ❑ Mud Rotary 0 Air Rotary ❑ Auger ❑ Cable Tool 0 Push Point ❑ Other SA <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gra U/IAdiameter <br />1-1ConductorCasing in diameter f Conductor Casing Depth ft A TN p aU'�TY <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched 0 Steel 0 Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth ft ❑ Neat Cement (94 Ib baa/5-90 gal water) u Sand Cement sack mix17 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumoed ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By 0 Driller ❑ Pump Contractor ❑ Other <br />0 Concrete Pedestal ❑Dimensions: Width ft Length ftThick <br />in 0 Christy Box 0 Stove Pipe <br />PUMP submersible❑ Turbine ❑ Other HP Pump Set ? ft Standing Water Level 02.5 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 B Date LZ Area I [ ( Employee ID# <br />Grout Inspection By Date ❑ SPECIAL Well Permit <br />Pump Inspection By Date i ❑ WAIVER Received <br />Soil Boring Inspection By - Date Constructed Well Depth ft <br />COMMENTS <br />�7_(, zv L5 <br />r 7 - <br />T <br />PE Sc Received <br />Codes Inffo7, B <br />Check#/ Amount Permitl <br />Cash emitted Date Service Re uest # Invoice # Well 04 <br />=043.06 10/25i2021 (?AW <br />_ Page I oft Well / Pump Pe mi: <br />