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FEMAILED WELL/PUMP PERMIT <br /> TY N SAN JOAQUIN COUNVIR MEN AL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PE 4 'CALL(209)953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS 10294 Comstock Rd. CITYIZIP Stockton, 95215 m <br /> CROSS STREET N. Stephens Rd. APN 08905035 <br /> PARCEL SIZE ® LAND USE APPLICATION# c <br /> M <br /> OWNER NAME David Miller PHONE 209-479-3649 N <br /> OWNER ADDRESS 20190 E. Comstock Rd. CITY/STATEIZIP Stockton, 95215 <br /> CONTRACTOR Purviance Drillers, Inc PHONE 209-887-3554 <br /> Po sox 64 Linden CA95236 <br /> Ili <br /> CONTRACTOR ADDRESS) CITYISTATEIZIP <br /> SUBCONTRACTOR A PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE X C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER 377923 EXPIRATION DATE 7/3 1 /2 7 <br /> DOMEsTIc WELLSAMPUNG: General Mineral/Cofiform Bacteria (4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE YDomestic/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 ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Wells) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical 1orin <br /> ❑ Out-Of-Service W II ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> CEIVEp <br /> ❑ New Pun um Re lacement ❑ Pum Re air ❑ Raise Well Casin <br /> WELL CONSTRUCTION �cww�•�. 20?5 <br /> Drilling Method ❑ Mud Rotary C Air Rotary ❑ Auger ❑ Cable Tool G Push Point Other $AN J <br /> Proposed Well Depth It Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft DEp 1ME�.e <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other_ � <br /> Grout Seal Depth ft ❑ Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack mix17 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method ❑ Pumped ❑ Free Fail ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br /> Li Concrete Pedestal❑Dimensions:Width ft Length It Thick <br /> in ❑ Christy Box Stove Pipe <br /> PUMP Submersible❑ Turbine ❑ Other HP 1 112 Pump Set 14 0 ft Standing Water Lovell 2 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 /> 24 1-a0€'I' A DV.sVNC'E;` O T ICE REQUIRED FOR iNSPEC.IONS-PLEASE'CzkLL(2(wl)9c3-7697 <br /> DEPARTMENT/ USE ONLY <br /> AA <br /> Application Accepted By Dat tp-L3'ZW%f- Area Employee ID# 5 T <br /> Grout Inspection By Date G SPECIAL Well Permit <br /> Pump Inspection By. Date E-I WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS J�l1)2 I{F f CardL 01� C�(1l,�Gf C(rd rM 1 MVC Zb&62rLe_ 1/,f OT IZ 7� <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B gash Remitted Service Re uest# <br /> 61 O p . Y6 6217 125 AP25m2223 <br /> Z5 B <br /> Imo , ram, <br /> MD041-06 014 07'2022 Z So j� Page I of 2 Weu;Pump Pemn i <br />