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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 />IV%JIV-ICtt-UNUAbLt rtKlVll I t,ALL ILUy) U04--lbUt FOR INSPECTIONS tXYIKt5 7 YEAR FROM DATE ISSUED <br />IJoBADDRESS 16240 E Comstock Rd CIN/ZIP Linden, CA 95236 <br />I/� , CROSS STREET Tully R d APN 0 91 O 9 D B 4 PARCEL SIZE 3 9. 4 QAND USE APPLICATION # <br />OWNER NAME Robert Freeman PHONE <br />OWNERADDRESS 16323 E Baker Rd CITY/STATEIZIP Linden, CA 95236 <br />CONTRACTOR Purviance Drillers, Inc PHONE209-887-3554 <br />PO Box 64 Linden, CA 95236 <br />CONTRACTOR ADDRESS CITY/STATE/ZIP <br />SUBCONTRACTOR n/ a <br />SUBCONTRACTOR ADDRESS <br />LICENSE gXC-57 ❑ C-61 ❑ D-09 ❑ Other <br />CITY/STATE/ZIP <br />NUMBER 3 7 7 9 2 3 EXPIRATION DATE <br />DOMESTIC WELL SAMPLING: 7 General Mineral/Coliform Bacteria (4391) I Dibromochlorc propane (4392) - Arsenic (4393) <br />INTENDED USE ❑ Domestic/Private X,rrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Oamer. Water System Name Contact Name or Phone Number <br />TYPE OF WORK <br />❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings p Geotechnical <br />❑ Out -Of -Service Well 0 Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />❑ New Pump 0 Pump Replacement -ffPump Repair t 11 Raise Well Casino <br />YYCLL'—UNJ1 KUUI IUN UgN�O -' 20 <br />22 <br />Drilling Method ❑Mud Rotary Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑ Other Ef�QL/r� <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom 0 Gravel Pack/Gravel SI �// meter <br />0 Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in ThicknessLGauge/ASTM Sched ❑ Steel ❑ Plastic C Stainless Steel 0 Other <br />Grout Seal Depth ft ❑ Neat Cement (94 lb bag/5-10 gal water) 0 Sand Cement sack mix/7 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By 0 Driller ❑ Pump Contractor vl Other <br />❑ Concrete Pedestal ❑Dimensions: Width ft Length ft Thick <br />�in ❑ Christy Box ❑ Stove Pioe , <br />PUMP ❑ SubmersibM Turbine ❑ Other HP '^, J Pump Set L`' ` > ft Standing Water Level ft <br />Plot Plan Requirements: Attach aplot 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 U E ONLY <br />Application Accepted By Date / Area / Employee <br />Grout Inspection By Date ❑ SPECIAL Well Permit <br />Pump Inspection By C Date 0 0 WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />y�d� <br />;r <br />m <br />D <br />0 <br />0 <br />I <br />I <br />f <br />PE SC Received <br />Codes Info By <br />Check#/ Amount <br />Cash emitted Date <br />Permitl <br />Service Request # Invoice # Well ID# <br />2 o.so <br />W P 0,1. -Y5 <br />I <br />I <br />Eiiil043-06 70!25L021 ���)R//�/. � / Y v /���� Pacelof2 WC11/punipper.mil <br />