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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 />IVUIV-KEFUNDABLE VERMIT FALL (LUy) yb.5-/b`J/ FOR 1NSPtC I IONS r -A1 IKMZ1 '1 T t --AR I KCIM UA fE ISSUED <br />JOSADDRESS 537 Meza Ct Crry/ZIP Linden,CA 95236 <br />CROSS STREET S Reid Rd APN 18336017 PARCEL SI7E2 - 0 LAND USE APPLICATION if <br />OWNER NAME Tony Ke r <br />Key � F'c>,�trlclCr 1kn(;l ScimEs xey --- PHONE <br />OWNER ADDRESS 537 Me z a C t CITYISTATEIZIPL i nde n, CA 95236 <br />CONTRACTOR Purviance <br />PO Box <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR n / a <br />(SUBCONTRACTOR ADDRESS <br />Drillers, Inc <br />64 <br />,LICENSE )QXC-57 ❑ C-61 ❑ D-09 ❑ Other <br />PHONE209-887-3554 <br />CITYISTATE/ZIP Linden, CA 95236 - <br />CITY/STATFJZIP <br />NUMBER 3 7 7 9 2 3 EXPIRATION DATE 7/ 31 / 2 3 <br />DOMESTIC WELL SAMPLING: � General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) i Arsenic (4393) <br />INTENDED USE I—,-)omestic/Private ❑ irrigation/Agricultural ❑ Industrial El Water Quality Monitoring ❑ Soil Sampling/Characterization <br />D Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK ❑ New Well M Replacement Well ❑ Well Alteration/Modification o Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings ❑ Geotechnical # of borings <br />❑ Out -Of -Service Well C Out Of -Service Well Renewal D Cross -Connection Repair <br />❑ New PumD "LPumo ReDiacement C PumD ReDaif ❑ Raise Well Casino <br />Drilling f4lethod E Mud Rotary a Air Rotary ❑ Auger C Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pac in diameter <br />C. Conductor Casing in diameter 1 Conductor Casing Depth ft RE - I V FD <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched D Steel ❑ Plastic ❑ Stainless Stee a the <br />Grout Seal Depth ft is Neat Cement (94 lb bag/5-10 gat water) ❑ Sand Cement k mW7 gal water <br />Bentonite (20% solids) ❑Other <br />Grout Placement Method ❑ Pumoed ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) _ <br />PEDESTAL Installed By ❑ Driller 0 Pump Contractor ❑ Other ENVI��UNIVIEN IAL <br />❑ Concrete Pedestal ❑Dimensions: Width ft Length ft Thick <br />in ❑ Christy Box ❑ Stove Pipe <br />PUMP ubmersible❑ Turbine ❑ Other HP Pump Set ft Standing Water Level 1 WU ft <br />Plot Plan Req irements: 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 3 o�oZ Area �/ 4C4 Employee 1D# <br />Grout Inspection By Date CI SPECIAL Well Permit <br />Pump inspection By 91/,CPUAJC Date 2 ❑ WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS frAjrlij�Ps bf ye)) <br />PE Sc Received Check#/ Amount D to Permit/ Invoice # Well ID# <br />Codes Info Cash Remitted , Service Re uest # <br />9361 Oso L . <br />1 <br />I I i <br />i <br />FHDO'3-05 10i25i2021Pap 1 of 2 lVen i Pump Perms <br />Co,) 4- 1q7 004,3103 <br />