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I WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />rvvrr-f`erulvuwtsLt r-tKMLI I:ALL ZU9 953-7697 FOR INSPECTIONS EXPIRES 9 YEAR FROM DATE ISSUED <br />IJOBADDREss4726 JAcktone Rd cnTYrza.Stockton,CA 95215 <br />ACROSS STREET <br />I OWNER NAME <br />OWNER ADDRESS <br />Fairchild Rd 'APN09104011 PARCEL SIZE 48.0 No USE APPLICATION # <br />Vaccrezza Bros VC, ce"rr z Z �iCtr Lr; h % ♦1 -1 �' l-\ (AC PHONE <br />8150 N Duncan RD CITYISTATE21PIinden,CA 95236 <br />CONTRACTOR Purviance Drillers, Inc <br />PO Box 64 <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR n/ a <br />SUBCONTRACTOR ADDRESS <br />LICENSE X�XC-57 ❑ G-61 ❑ D-09 ❑ Other <br />PHONE209-887-3554 <br />CITY/STATEMP Linden, CA 95236 <br />CITY/STATE/ZIP <br />PHONE <br />EXPIRATION DATE _.7_L3 1 / 2 3 <br />DOMESTIC WELL SAMPLING: 7 General Mineral/Coliform Bacteria (4391).-, Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE ❑ DomestiGPrivate Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Ovmer. <br />TYPE OF WORK ❑ New Well ❑ Replacement Well <br />❑ Monitoring Well(s) # of wells <br />❑ Out -Of -Service Well <br />❑ New Pump4 Pump Replacement <br />Water System Name <br />❑ Well Alteration/Modification <br />❑ Soil Boring(s) <br />❑ Out -Of -Service Well Renewa <br />Contact Name or Phone Number <br />❑ Other <br />4 of borings ❑ Geotechnical <br />1 ❑ Cross -Connection Repair <br />❑ Raise Well Casino <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Catile Tool ❑ Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter :1 Open Bottom 0 Gravel Pack/Gravel <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel <br />Grout Seal Depth ft ❑ Neat Cement (94 lb bag/5-10 gal water) ❑ Sand Cement <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PE <br />DESTAL Installed By ❑ Driller El Pump Contractor ❑ Other <br />❑ Concrete Pedestal ❑Dimensions: Width it Length ft Thick <br />❑ Christy Box ❑ Stove Pipe <br />❑ Other `f <br />sack <br />HUMP ❑ Submers-ible'V 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 r� '� Area Employee ID# tr = i <br />Grout Inspection By Date ❑ SPECIAL Well Permit <br />Pump Inspection By Date ❑ WAIVER Received <br />Sail Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS 3 c>t `3iI — 11—l, 13 -1 4"'L <br />PE Sc Received Check#/ Amount Permit/ <br />Codes Info ash Remitted Date Service Re uest # Invoice # Well ID# <br />-7 7 <br />EHDO43-06 10/'_52021 Page I ort Well / Pump Permit <br />I�411 f 9 7 n <br />T <br />