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01- <br />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 CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />Comstock Rd CITYlzIP Linden,CA 95236 <br />JOB ADDRESS <br />Tully Rd APN 0 91 0 9 0 3 3 PARCEL SIZE 19.91 <br />LAND USE APPLICATION # <br />:ROSS STREET <br />v; r-tc)r zolezzi <br />OWNER NAME <br />OWNER ADDRESS <br />14807 E Eight Mile Rd <br />CONTRACTOR Purviance Drillers, Inc <br />PO Box 64 <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR n/a <br />SUBCONTRACTOR ADDRESS <br />_ICENSE --r-57 Li C-61 ❑ D-09 ❑ Other <br />nihrmmochloroorooane (4392) _ Arsenic (4393) <br />PHONE <br />CITY/STATE17jP Linden , CA 95236 <br />PHONE209-887-3554 <br />CI7YISTATEIZIP Linden, CA 95236 <br />CITY/STATE/ZIP <br />NUMBER 377923 EXPIRATION DATE 713 1 23 <br />DOMESTIC WELL SAMPLING: _ heneral minufd-01110,111­­­ r - - - <br />INTENDED USE ❑ Domestic/Private Irrigation/Agricultural U Industrial ❑ water Quality Monitoring j Soil Sampling/Characterization <br />U Public Water System Contact Name or Phone Number <br />If dfferent from Owner Water System Name <br />M r)ti— <br />TYPE OF WORK I7 New Well a Replacement even u uvea rutciau� w �.' <br />Ll Monitoring Well(s) # of wells ❑ Soil Boring(s). # or borings ❑ Geotechnical <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal C Cross -Connection Repair RECEIVED <br />C New Pum , Pum Replacement Pum Re air �ci�,; `1 ❑Raise Well casing ^ <br />WELL CONSTRUCTION SEP 0 1 int? <br />Drilling Method L: Mud Rotary L3 Air Rotary ❑ Auger ❑ Cable Tool u Push Point F1 Other <br />Proposed Well Depth ft Excavation in diameter L' Open Bottom ❑Gravel Pack/Gravel in diameter <br />IN COUNT <br />Conductor Casing in diameter / Conductor Casing Depth ft ENVIRONMENTAL <br />Steel ❑ Plastic G Stainless Steel kf: t 4fH <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched sackmpr a04 <br />Grout Seal Depth ft U Neat Cement (94 lb bag/5-10 gal water) Sand Cement 9 <br />0 Bentonite (20% solids) n Other <br />El Retardant !Accelerator (name) <br />Grout Placement Method F]Pumped ❑ Free Fall [-_1Other <br />PEDESTAL Installed By [7 Driller ❑ Pump Contractor <br />Ll Concrete Pedestal ❑Dimensions: Width — <br />in ❑ Christy Box n Stove Pipe <br />n Other - <br />ft Length <br />ft Thick <br />PUMP ❑ Submersible l Turbine ❑ Other HP -2-0 Pump Set ft Standing Water LevelI� ft <br />Plot Plan Requirements: Attach a plot plan with the exact location of water wel with respect to the following items: GPS <br />Coordinates, property lines, adjoining properties, water bodies or courses, drainage pattern, roads, existing welts, 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 <br />X_ <br />fdNLY <br />,p <br />I/ZZ <br />r� Employee ID# <br />AreaL <br />Application Accepted B <br />Date <br />[I SPECIAL Well Permit <br />Grout Inspection By <br />Date <br />Date iy� <br />L; WAIVER Received <br />Pump Inspection By <br />Constructed Well Depth ft <br />Soil Boring Inspection By <br />Date <br />COMMENTS <br />-- <br />Permit/ <br />PE SC Received Check#/ Amount Date Service Re <br />Codes Info B Cash R mined <br />ERD043.06 10:25/2021 Page 1 01`2 <br />Invoice # I Well ID# <br />Well I Pump Permit <br />