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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 />..n.. <br />— -r•crU1MUPkMLt rtKMI1 LALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 11870 E Eight Mile RD <br />cITY/ZIPStockton,CA 95215 <br />CRosssrREEr Jacktone RD gpN0891 4025 L <br />PARCEL $IZE f,r—' LAND USE APPLICATION # <br />OWNERNAME Vaccarezza Bros :3 ,gljzE Dom (1lFC%/F t+/ PHONE <br />OWNERADDREss 81 50 N Duncan RD L",t lv1 ,� F r �a <br />Cmr/STATE/ZIP Linden, CA 95236 �c Oji <br />CONTRACTOR Purviance Drillers, Inc PHONE209-887-3554 <br />CONTRACTOR ADDRESSP <br />O BOX 64 CrrY/STATE21P Linden, CA 95236 <br />SUBCONTRACTOR n/ a <br />SUBCONTRACTOR ADDRESS <br />LICENSE XS)C 57 0 G-61 ❑ D-09 ❑ Other <br />PHONE <br />CITY/STATEOP <br />NUMBER 377923 EXPIRATION DATE <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloronronnnp td309l , Arcanir rdgo4� <br />INTENDED USE 0 DomesticJPrivate 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 0 Other A y <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s)# of borings n H <br />❑ Geotechnical <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />0 New Pump 0 Pump Replacement r�(Pump Repair_ ❑ Raise Well Casino dd. <br />tj <br />Drilling Method ❑Mud Rotary❑ Air Rotary 0 Auger ❑ Cable Tool ❑ Push Point 0 Other 11SqN✓p �Q?� <br />Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gr� ( /eFFtQi�meter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft DFpq lyT��VTy <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic 0 Stainless Steel ❑ Other RTS_ <br />Grout Seal Depth ft 11Neat Cement (94 lb bagIS-90 gal water) ❑ Sand Cement sack mixl7 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall 0 Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor <br />❑ Concrete Pedestal ❑Dimensions: Width_ <br />in ❑ Christy Box ❑ Stove Pioe <br />❑ Other <br />ft Length <br />ft Thick <br />!UMP `(Submersible❑ Turbine ❑ Other HP �O 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 1 Z_ <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />Date $ .a .2,; <br />Date <br />Date <br />Date <br />Area — q Zt / Employee ID# Ffli 11 /< <br />0 SPECIAL Well Permit <br />0 WAIVER Received <br />Constructed Well Depth <br />ft <br />N <br />PE <br />Codes <br />SC Received Check#/ <br />Info Cash <br />Amount <br />Remitted Date <br />Permitl <br />Service Re uest# Invoice# WellID# <br />3 8 <br />-o <br />22 <br />9 5- <br />I <br />Page I or2 Well /Pump Permit <br />m <br /><3t� <br />