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- 1 _ (A`�_IVr- WELL/PUMP PERMIT <br /> SAN JOAQUIN CO�NTti1ROIV�AtlXli DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT \—/ CALL(209)953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS 12425 E Comstock Rd CITY/ZIP Stockton m <br /> Jackt-Tone Rd 08916003 g <br /> CROSS STREET APN PARCEL SIZE 3 2 LAND USE APPLICATION# O <br /> Pam Salmon Trust m <br /> OWNER NAME PHONE vi <br /> OWNER ADDRESS 7986 Beecher Rd CITY/STATE/ZIP Stockton, CA 95212 <br /> CONTRACTOR <br /> Purviance Drillers, Inc PHONE 209-887-3554 <br /> PO Box 64 Linden CA95236 <br /> CONTRACTOR ADDRESS CITY/STATEIZIP � <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE X C-57 C C-61 ❑ D-09 ❑ Other NUMBER 377923 EXPIRATION DATE 7/31 /2 7 <br /> DOMESTIC WELL.SAMPLING: )(General Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE X Domestic/Private ❑ IrrigationlAgricultural ❑ Industrial a 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 /> i Monitoring Well(s) #of wells ❑ Soil Boring(s) €f of borings ❑ Geotechnical � r7 <br /> Out-Of-Service Well — <br /> ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair C�,.�` <br /> ❑ New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION JA <br /> Drilling Method a Mud Rot ry ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other '-vll J�02R <br /> Proposed Well Depth$ ft Excavation in diameter Lf Open Bottom ❑ Gravel Pack/G V1 n diameter <br /> Conductor sing in diameter / Conductor Casing Depth ft �77 DF"�IIFj�� r <br /> Well Casing Diameter �D n Thickness/Gauge/ASTM Sched f S(v IR Steel ❑ Plastic ❑ Stainless Steel ❑ QUA <br /> Grout Seal Dep - 2t, ft D. Neat Cement(94 Ib bag15-10 gal water) )e Sand Cement 10.3 sack mix al water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method X Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller ❑ Pump Contractor ❑ Other <br /> ❑ Concrete P destal❑Dimensions:Width ft Length ft Thick <br /> in ❑ Christy Box ❑ Stove Pipe <br /> DUMP ❑ 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 /> _-AII'JiAnl'�i 23 HOOP,_D _ NCE:tit3710E 1-117QUIRED FOR iNSPECT10-XS-PIA-As CALL(209)1,3-7697 <br /> DEPARTMENT U (E� NLY <br /> Application Accepted By Date 1 r Area /7 Employee ID# <br /> Grout Inspection uy Date SPECIAL Well Permit <br /> jiJ <br /> Pump Inspection By Date 0 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENT c/ ti� /1G <br /> PE SC Received Check#1 Amount Date Permitl Invoice# Well ID# <br /> Codes Into BY Cash Remitted Service Request# <br /> (t iy - - -Z <br /> 3 / ill <br /> E14DO43-06 04 07,1022 J �� �� f Pare 1 of 2 W,ll'Pump Permit <br />