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1 WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 -(209)4883420 NON-REFUNDABLE PERMI��T CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOD ADDRESS CITY21P_ � 95-J3 4 m CROSS STREET /6u led. APN /F-J3 2,yo(O PARCEL SIZE (05L LAND USE APPLICATION# p OWNER NAME CiArt=Brei T ;;nd Gat;t=le Ra,, l i al P14ONE 209-327-3232 u OWNER ADDRESS 334 halako CITY/STATErziFOakdale CA 95361 CONTRACTOR Purviance Drillers, Inc PHONE 209-887-3554 CONTRACTOR ADDRESS PO Box 64 CITYISTATE2IP Linden, CA 95236 SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZiP LICENSE Xr G-57 O C-61 ❑ D-09 ❑ Other NUMBER 377923 EXPIRATION DATE 7/31 /2 5 DOMESTIC WELL SAMPLING:::General Mineral/Coliform Bacteria (4391) 1 Dibromochloropropane(4392) -!Arsenic(4393) INTENDED USE ❑ Domesfic/Pdvate><IrrigationfAgricultuml ❑ Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization ❑ Public Water System_ If different from Ovines Water System Name Contact Name or Phone Number TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical c /v ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair ` ❑ New Pump ❑ Pump Replacement X—/PUmp Repair ❑ Raise Well Casing WELL CONSTRUCTION SA Drilling Method ❑ Mud Rotary LlAir Rotary ❑Auger ❑Cable Tool ❑ Push Point ❑ Other Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gra $ _ONnn^Cmeter ❑ Conductor Casing in diameter / Conductor Casing Depth ft Fpry Well Casing Diameter, in ThicknesslGaugelASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other BENT Grout Seal Depth ft ❑ Neat Cement(941b bag/5-10 gal wafer) D*Sand Cement sack m&7 gal water ❑ Bentonite(20%solids) ❑ Other Grout Placement Method ❑ Pumped ❑ Free Fail ❑ Other ❑ Retardant/Accelerator(name) PEDESTAL InsMiled By D Driller ❑ Pump Contractor ❑ Other ❑ Concrete Pedestal❑Dimensions:Width ft Length ft Thick 1n ❑ Christy Box ❑ Stave Pipe e PUMP n Submersible Turbine ❑ Other HPC Pump Set /90 ft Standing Water Level 1—�ft Plot Plan Requirements: A ach 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. ' FQLfREJ rOR PSP€CTOS-Pr- SE C 1.T.(20)9§376971 ?vail 34;DUR:� J :O�\CtCE ig f DEPARTMENT USA ONLY L� Application Accepted Date — / ' 9 � Area // Employee ID# Grout Inspection By Date O SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS PE SC Received Check#] Amount Date Permitf Invoice# Well ID* Codes Info By Cash Remitted Service Re uest# y3�'Z OSD $' 77 ;zt i(t I z3 wPm(1,ti-51,42 EIiD033-000x:0?^-0" �' _J � �� ! Sly�7-/ 1 Pace lof2 Well;Pump Parmi;