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1 WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />IVVIV-MI=I-UNUAbLt t'L^UYII I t ALL <br />JOB ADDRESS 18917 E Baker Rd <br />y53 -/by/ FOR INSPECTIONS t_XVIKtJ I YEAR FROM UATE ISSUED <br />CROSS STREET Cox Rd APN 09124019 <br />OWNER NAME Max Copello / Rollin' Ranch <br />OWNER ADDRESS PO Box 562 <br />CONTRACTOR Purviance Drillers <br />PO Box 64 <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR n/ a <br />Inc <br />SUBCONTRACTOR ADDRESS <br />LICENSE >P�C-57 ❑ C-61 ❑ D-09 ❑ Other <br />CITYp/zipLinden, CA 95236 <br />SIZES • 8 5 LAND USE APPLICATION # <br />PHONE <br />CITY/STATEJZIP Linden,CA 95236 <br />PHONE209-887-3554 <br />CITYISTATE/ZIP Linden, CA 95236 <br />PHONE <br />CIN/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 />NTENDED USE ❑ Domestic/Private'Irrigation/Agricultural ❑ Industrial U Water Quality Monitoring U Soil Sampling/Characterization <br />Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK U New Well D Replacement Well ❑ Well Alteration/Modification G Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings ❑ Geotechnical <br />❑ Out -Of -Service Well 171Out-Of-ServiceWell Renewal Ill Cross -Connection Reneir �A-,,NPA. <br />❑ New Pump ❑ Pump Replacement Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other S �P <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Grav�t A^• d ameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft �fF'14 /-�Rn—o�N�M7N—COU <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic U Stainless Steel ❑ GATgF/V� <br />Grout Seal Depth ft ❑ Neat Cement (94 Ib bagl5-10 gal water) ❑ Sand Cement sack i l water <br />U Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By C Driller D Pump Contractor " Other <br />❑ Concrete Pedestal GDimensions: Width ft Length ft Thick <br />�in ❑ Christy Box U Stove Pipe _ t <br />PUMP ❑ SubmersibleV4Turbine ❑Other HP I Pump Set—d- i I 1ft Standing Water Level 1 (( .: 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 USt PINLY <br />p G < <br />Application Accepted By / Date Area L 1 Employee ID _ ' <br />Grout Inspection By Date G SPECIAL Well Permit <br />Pump Inspection By bl-I Date "�� l� j��` ❑ WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />PE Sc Received Check#/ Amount Permit/ <br />Codes I Info B Cash emitted Date Service Re uest# Invoice # Well ID# <br />U b l '. ' "P0-DqZ' <br />FHD043-067025/1021 /i // Pagc Iof'- Well/Pump Permit <br />T <br />m <br />D <br />0 <br />a <br />m <br />rn <br />W <br />