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of <br />1 WELLIPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />CYD1P1=q I Yr -AR FRnM DATE ISSUED <br />NON-REFUNDABLE PERMIT FALL r — <br />G <br />JOB ADDRESS 6697 N Co CITY/ZIP Linden CA 95236 — <br />R <br />3 <br />/}9 y1 <br />Comstock RD APN v I �� I Ol ✓ PARCEL SIZE .O3 LAND USE APPLICATION <br />CROSS STREET <br />n <br />PHONE209-887-3618 <br />u <br />OWNER NAME Gary Marciano <br />6697 N COX Rd CITYISTATEiZIP Linden CA 95236 <br />OWNER ADDRESS <br />Purviance Drillers, Inc PHONE209-887-3554 <br />CONTRACTOR <br />PO Box 64Linden, CA 95236 <br />CITYISTATElZIP <br />CONTRACTOR ADDRESS <br />n / a PHONE <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS CITY/STATEIZIP <br />LICENSE V,XC-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER 377923 EXPIRATION DATE 713 1 / 2 3 <br />DOMESTIC WELL SAMPLING: -- General Mineral/Coliform Bacteria (4391) – Dibromochloropropane (4392) -- Arsenic (4393) <br />INTENDED USE Domestic/Private D Irrigation/Agricultural G Industrial ❑ Water Quality Monitoring D Soil SamplinglCharacterization <br />Public Water System <br />If different from Ovmer. Water System Name Contact Name or Phone Number <br />TYPE OF WORK ❑ New Well a Replacement Well D Well Alteration/Modification ❑Other <br />I of borings # of borings <br />❑ Monitoring Well(s) of wells D Soil Boring(S) [} Geotechnical <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />❑ New Pump ❑ Pump Replacement _ ��ump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool D Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br />E Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel D Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth ft ❑ Neat Cement (94 /b bagl5-10 gal water) ❑ Sand Cement sack mix17 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall 0 Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By D Driller D Pump Contractor ❑ Other <br />❑ Concrete Pedestal ❑Dimensions: Width ft Length ft Thick <br />in ❑ Christy Box ❑ Stove Pipe <br />PUMP Submersible❑ Turbine ❑ Other HP_ Pump Seft Standing Water Level j�S ft <br />Plot Plan Re uirements: 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 USE ONLY <br />Application Accepted By <br />l� V Date <br />Grout Inspection By k Date <br />Pump Inspection By 7 Date <br />Soil Boring Inspection By Date <br />COMMENTS jPac-)rr it ! `(a - �"✓�' <br />53,-D-1 i -I 1 <br />Area Employee lD# <br />1 SPECIAL Well Permit <br />C WAIVER Received <br />Constructed Well Depth ft <br />PE SC Received Check91 Amount Date Permit/ Invoice # <br />Codes Info By Cash I Remitted Service Re uest# <br />SAN <br />AGUIN COU <br />HEA T� L <br />I I . <br />I <br />CJ <br />EHD0,3-06 10125i2021 Parc i ort WcI1lPump Pcmir <br />C Out i'� I -7 © 2, 4 5–('N <br />() <br />