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I WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED JOB ADDRESS 8440 N Tully Rd CITYIZIP Linden Eight Mile Rd 09108007 g7/ CROSS STREET APN PARCEL SIZE � LAND USE APPLICATION # OWNER NAME Lawrence Sambado PHONE OWNER ADDRESS CITYISTATEIZIP PO Box 461 Linden, CA 95236 i CONTRACTOR Purviance Drillers, Inc PHONE209-887-3554 PO Box 64 Linden, CA 95236 CONTRACTOR ADDRESS CITYISTATE/ZIP SUBCONTRACTOR n / a PHONE SUBCONTRACTOR ADDRESS CITYISTATE/ZIP LICENSE X)CC-57 00-61 0 D-09 Cl Other NUMBER 377923 EXPIRATION DATE 7/ 31 / 2 3 DoMEsnc WELL SAMPLING: = General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) INTENDED USE A Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring G Soil Sampling/Characterization ❑ Public Water System If different from Owner. Water System Name Contact Name or Phone Number TYPE OF WORK ❑ New Well 0 Replacement Well 0 Well Alteration/Modification 0 Other ❑ Monitoring Well(s) # of wells ❑ Soil Boring(S) K of borings 0 Geotechnical #of bo s VE Q G Out -Of -Service Well 0 Out-Of-ServiceWellRenewal ❑ Cross -Connection Repair SEP 28 ❑ New Pum 0 Pum Replacement um Repair ` f% ❑ Raise Well Casing WELL CONSTRUCTION JOAQUI Drilling Method 0 Mud Rotary C3 Air Rotary ❑ Auger ❑ Cable Tool 0 Push Point 0 Other ii ENVIRON N COUNT Proposed Well Depth ft Excavation in diameter 0 Open Bottom ❑ Gravel Pack/Gravel S¢e PARJ ter Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic 0 Stainless Steel 0 Other Grout Seal Depth ft ❑ Neat Cement {941b bagl5-10 gal water) El Sand Cement sack mix/7 gal water ❑ Bentonite (20% solids) 0 Other Grout Placement Method ❑ Pumped ❑ Free Fall 0 Other 0 Retardant /Accelerator (name) PEDESTAL Installed By ❑ Driller 0 Pump Contractor u Other 0 Concrete Pedestal ❑Dimensions: Width it Length ftThick in 0 Christy Box ❑ Stove Pipe PUMP Submersible0 Turbine ❑Other HP 2 Pump Set ft Standing Water Level 175 ft Plot Plan Requirements: Attach, a plot plan with the exact location of water well with respect to the following items: GPS Coordinates, property lines, adjoining properties, water bodies or courses, drainage pattern, roads, existing wells, structures, potential sources of contamination, sewers or private disposal systems. Include distance from two property lines. For Domestic, Agriculture, Industrial well, provide location of any water wells or surface water within 200' radius of proposed well. DEPARTMENT USE ONLY Application Accepted By `� Date n Area q1 rl / Employee IDm f • I h �� Grout Inspection By Date U SPECIAL Well Permit Pump Inspection By Date y ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS "l, t'_Ji PE I SC Received Codes Info B Check#/ Cash I Amount Permit/ Remitted Date ervice Request # Invoice # Well ID # dtv enc -as ro,>seo�l Pa_: I c 11'dl / Pump Pcmi;