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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 /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 29450 N St Rt 88 Hwy ¢ CA <br /> CITY/ZIP <br /> m <br /> pn D <br /> CROSS STREET Village Rd APN 00 936o04, PARCEL SIZE C J, LAND USE APPLICATION# p <br /> OWNER NAME Beck Ranch l 1 209-604-2222 m <br /> f—�y VP{ �(7rS�F , 1 �Y3� PHONE y <br /> OWNER ADDRESS 8102 Kelly Dr Suite C CITY/STATE/ZIP Stockton, CA 95209 <br /> CONTRACTOR Purviance Drillers, Inc PHONE209-887-3554 <br /> PO Box 64 Linden CONTRACTOR ADDRESS CITY/STATE/ZIP CA 95236 <br /> SUBCONTRACTOR n/a PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE kXC-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER 377923 EXPIRATION DATE 7/3 1 /2 3 <br /> DOMESTIC WELL SAMPLING:'General Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE ,$i Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> ❑ Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK X New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other / <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #or borings ❑ Geotechnical #of bon <br /> �o <br /> El Out-Of-Service Well El Out-Of-Service Well Renewal -1 Cross-Connection Repair <br /> ❑ New Purne ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well CasingAAI <br /> WELL CONSTRUCTION <br /> Drilling Method XMud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other h�T�/RONM C <br /> Proposed Well Depth .550 ft Excavation /w 514 in diameter X Open Bottom ❑ Gravel Pack/Gravel Size Rd ameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter��in Thickness/Gauge/ASTM Sched P Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth �=) ft ❑ Neat Cement(94 lb bagi5-10 gal water) X Sand Cement 10. 3 sack mix17 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By 'I(Driller ❑ Pump Contractor / ❑ Other <br /> ❑ Concrete Pedestal%Dimensions:Width_�Ge�.dQ�tgth ft Thick <br /> n ❑ Christy Box ❑ Stove Pipe <br /> PUMP ❑ Submersible❑ Turbine ❑ Other HP Pump Set ft Standing Water Level 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 USE ONLY <br /> Application Accepted By Date a� .f',+ Area Employee ID# +1 <br /> Grout Inspection By f_�� Li i l ;� Date q�(Y(2� ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth �(✓) ft <br /> COMMENTS <br /> PE SC Received Amount Permit/ <br /> Codes Info Cash Remitted Date Service Request# Invoice# Well ID# <br /> ysi�'F" I Z -L <br /> Zc,I 2212— f 1,o I W 0 <br /> EKD043-06 10/25/2021 Page l of 2 Well/Pump Permit <br />