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+1 <br />I WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN -REFUNDABLE PERMIT UALL (ZUy Jb.5-/10UI FOR INbi tL:IIUNb cArlr«o I r rAm r-mumvAl r- IJJUGu <br />JOB ADDRESS 16850 E Frazier Rd CITY/ZIP Linden,CA 95236 <br />CROSS STREET N. Tully Rd <br />OWNERNAME Brian Mellor (KI <br />OWNER ADDRESS P.0 Box 794 <br />APN 06510024 PARCEL SIZE2 7 • 14 LAND USE APPLICATION # /' / <br />IQICY) PHONE i5 D, (( —)S` / - U t / `[ r <br />CITY/STATE/ZIP Linden,CA 95236 <br />CONTRACTOR Purviance Drillers, Inc <br />PO Box 64 <br />CONTRACTOR ADDRESS <br />n/a <br />SUBCONTRACTOR ADDRESS <br />LICENSE X)�C-57 ❑ C-61 C D-09 ❑ Other <br />PHONE209-887-3554 <br />CITY/STATE/ZIP Linden, CA 95236 <br />CITY/STATE/ZIP <br />NUMBER 377923 EXPIRATION DATE 7/ 31 / 2 3 <br />DOMESTIC WELL SAMPLING: --General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE ❑ Domestic/Private Irrigation/Agricultural ❑ Industrial El Water Quality Monitoring ❑ Soil Sampling/Characterization <br />❑ Public Water Syst m <br />If different from Owner. Water System Name Contact Name or Phone Number <br />TYPE OF WORK ❑ New Well ❑ Replacement Well U Well Alteration/Modification <br />❑ Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings ❑ Geotechnical 44f borings <br />r+�%�� <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal <br />❑ Cross -Connection Repair <br />C1 New Pum ❑ Pum Replacement Pum Repair <br />13 Raise Well Casing&,Y <br />WELL CONSTRUCTION , <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point <br />❑ Other $EP n <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom C1Gravel Pack/Gravel§re- n dl(31eter <br />❑ Conductor Casing in diameter / Conductor Casing Depth <br />1� <br />ft EN 04 Q�U�14 <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel <br />U Plastic ❑ Stainless Steel { OY <br />Grout Seal Depth ft U Neat Cement (94 lb bag/5-10 gal water) <br />D Sand Cement sa r <br />0 Bentonite (20% solids) ❑ Other <br />Grout Placement Method :� Pumped 0 Free Fall U Other Retardant <br />/ 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 ❑ Submersible[Sturbine ❑ Other HP `ri-`rr c ) Pump Set , U"I ft Standing Water Level , '(,.U 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 USIF Ly <br />Application Accepted By Date 9 22 Area / / Employee ID#tel <br />Grout Inspection By Date Ll SPECIAL Well Permit <br />Pump Inspection By Date Ca L j � � ❑ WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />T <br />-4 <br />rn <br />D <br />v <br />m <br />m <br />PE Sc Received Check#/ <br />Codes Info B Cash <br />Amount Permit/ <br />Remitted Date Service Re uest# Invoice # Well ID# <br />oS0 <br />EHDW3-06 1025/2021 Page 1 of2 <br />%V 11 / Pump P—it <br />