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i <br />a <br />1 WELLIPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUIV-KEFUNDABLE PERMIT L.ALL ZUy ybS-t OU( FOR INSPEGTIUNS CJCt'IKCJ 1 ThAK FROM LJAI t 165UEU <br />JOB ADDRESS 12023 E Eight Mile Rd CITY/71P Stockton, CA 95212 <br />CROSS STREET Jacktone Rd APN 06320017 PARCEL SIZER 6 . 8 9 LAND USE APPLICATION # <br />OWNER NAME T.,Alira RAwA_N17nf-py- PHONE <br />OWNER ADDRESS 3271 MacInol l a AVP_ CITY/STATE/ZIP C1OViS , CA 9361 1 <br />CONTRACTOR Purviance Drillers, Inc PHONE209-887-3554 <br />PO Box 64 Linden, CA 95236 <br />CONTRACTOR ADDRESS CITY/STATE21P <br />SUBCONTRACTOR n / a PHONE <br />SUBCONTRACTOR ADDRESS CITYISTATE/ZIP <br />LICENSE XXC-57 ❑ C-61 17 D-09 11 Other 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 />NTENDED USE `<Domestic/Private ❑ IrrigationlAgricultural 7 Industrial fl 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 ❑ New Well - Replacement Well ❑ Well Alteration/Modification C Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings G Geotechnical # of borings <br />L Out -Of -Service Well '1 Out -Of -Service Well Renewal C Cross -Connection Repair <br />P <br />Drilling Method ❑ Mud Rotary Air Rotary it Auger P. Cable Tool 71 Push Point LI Other <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel P t'AftM E in diameter <br />C Conductor Casing in diameter / Conductor Casing Depth ft �tECENED <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel 11, Plastic ❑ Stain ess Steel ❑Other <br />Grout Seal Depth ft ❑ Neat Cement (94 lb bag/5-10 gal water) ❑ Sand Cement Al H sack mix/7 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped n Free Fall ❑ Other ❑ Retardant ! Accelerator (nawo)JoAolli" couNTY <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor r Other <br />❑ Concrete Pedestal ❑Dimensions: Width ft Length ft Thick <br />�in L Christy Box ❑ Stove Pipe <br />PUMP Submersible❑ Turbine ❑ Other HP Pump Set \fit I'ft Standing Water Level u ' f 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 �' �' L Date <br />Grout Inspection By Date <br />Pump Inspection By Date ( C, <br />Soil Boring Inspection By Date <br />COMMENTS d�,r,!;�! f :� C�TJ D'� IV?it_ 5 �„/P_1 1_ <br />Area <br />Employee ID# Ff ,ni k <br />LI SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth ft <br />PE <br />Codes <br />SC Received Check#/ <br />Info Cash <br />Amount Dat <br />Remitted I <br />Permit/ Invoice # Well ID# <br />Service Request # <br />3 f'd <br />J <br />hAc <br />3y 51 <br />F.M043-06 )0125/2021 <br />Page 1 of 2 1/ / , / ^ � r � � /,r � �j I��/�� Nell /Pump Pcrn,it <br />