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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 />IVU1N-Mtl-UNUAIJLt rtRMl l t ALL (LUU) U06-/bUt FOR INSPECTIONS tAVIKtJ 'I YEAR FROM UATE ISSUED <br />JOB ADDRESS 13664 E Pinto Ln CITY/ZIP Lodi,CA 95240 <br />CROSS STREET Pony Ln APN 05302014 PARCELSIZE . 6 2 LAND USE APPLICATION # <br />OWNER NAME Olen Hampton PHONE <br />OWNERADDRESS 13664 Pinto Ln CITY/STATE/ZIPLodi, CA 95240 <br />CONTRACTOR Purviance Drillers, Inc PHONE209-887-3554 <br />PO Box 64 Linden, CA 95236 <br />CONTRACTOR ADDRESS CITYISTATE/ZIP <br />SUBCONTRACTOR n / a <br />SUBCONTRACTOR ADDRESS <br />LICENSE )Q�C-57 ❑ C-61 E D-09 ❑ Other <br />CITY/STATE/ZIP <br />NUMBER 377923 EXPIRATION DATE 7 2 3 1 1 2 3 <br />DOMESTIC WELL. SAMPLING: = 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 ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings ❑ Geotechnical # of 421; <br />❑ Out -Of -Service Well F3 Out -Of -Service Well Renewal ❑ Cross -Connection Repair Rz�Y mp <br />❑ New Pum ❑ Pump Replacement Pump Repair v I ❑Raise Well Casin ; t <br />WELL CONSTRUCTION ��� 0 <br />Drilling Method 11 Mud LI Rotary ❑ Air Rotary Auger ❑ Cable Tool Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel SIZe~N in diaHW <br />C Conductor Casing in diameter / Conductor Casing Depth ft i`y qq��NTT OVIN <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched L' Steel 11 Plastic ❑ Stainless Steel D Oth�t/1 NI��CO(/l� <br />Grout Seal Depth ft ❑Neat Cement (94 Ib bag/5-10 gal water) ❑Sand Cement sa71"'" <br />x a�Ap <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall L Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal ❑Dimensions: Width ft Length ft Thick <br />n ❑ Christy Box ❑ Stove Pipe <br />PUMP `~,Submersible❑ Turbine ❑ Other HP Pump Set I" 1U; ft Standing Water Level ;=_n.' 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 />EPARTMENT U NLY <br />Application Accepted By Date 0/ C !� Area Employee 10# <br />Grout Inspection By Date ❑ SPECIAL Well Permit <br />Pump Inspection By A Date t ' ❑ WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />at 1. <br />T <br />m <br />n <br />0 <br />Q <br />m <br />m <br />y <br />1T <br />PE SC Received <br />Codes Info B <br />Check#/ Amount Permits <br />ash emitted Date Service Request # Invoice # Well ID# <br />0 <br />P o 2 <br />EHD043-06 10!2512021 Page I ort R'ell /Pump Permit <br />