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Jos ADDRESS 2000 N Duncan RD crrvizip L Lad e n , CA 9 5 2 3 6 <br />CROSS STREET Wagner Ln ApN 1 051 401 6 PARCEL sizi2 6 . 2 2 LAND USE APPLICATION # <br />OWNER NAME Mike Berg <br />OWNER ADDRESS PO Box 739 CITY/STATE/ZIP T, i nclPn CA 9 2 'I <br /> <br />PHONE <br />CONTRACTOR <br />SUBCONTRACTOR <br />Purviance Drillers, Inc <br />II/ a <br />PHONE 209-887-3554 <br />Linden, CA 9 523 6 CITY/STATE/ZIP <br />PHONE <br />CITY/STATE/ZIP <br />PO Box 64 <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR ADDRESS <br />LICENSE XAC-57 0 C-61 0 D-09 0 Other NUMBER 3 7 7 9 2 3 EXPIRATION DATE 7 / 3 1 / 23 <br />QUN GOtiNtr ENVIRONMENTAL HEALY " Di_vAR iNIENT <br />N IMA <br />1 WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />DOMESTIC WELL SAMPLING: 7: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE Domestic/Private 0 Irrigation/Agricultural 0 Industrial Water Quality Monitoring El Soil Sampling/Characterization <br />Public Water System <br />If different from Owner. Water System Name <br /> <br />Contact Name or Phone Number <br />TYPE OF WORK 0 New Well CI Replacement Well 0 Well Alteration/Modification 0 Other <br />El Monitoring Well(s) # of wells 0 Soil Boring(s) # of borings 0 Geotechnical # of borings <br />Out-Of-Service Well 0 Out-Of-Service Well Renewal 0 Cross-Connection Repair <br />New Pump 0 Pump Replacement le Pump Repair )21/..,terg,/,..a. 0 Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method 0 Mud Rotary 0 Air Rotary 0 Auger 0 Cable Tool 0 Push Point o Other <br />Proposed Well Depth ft Excavation in diameter 0 Open Bottom 0 Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />2022 <br />PAYMENT- Well Casing Diameter in Thickness/Gauge/ASTM Sched 0 Steel 0 Plastic 0 Stainless Steel 0 Other <br />Grout Seal Depth ft 0 Neat Cement (94 /b bag/5-10 gal water) 0 Sand Cement sack mi)17?1E gtYCVer <br />Bentonite (20% solids) 0 Other SEP 0 9 <br />Grout Placement Method 0 Pumped 0 Free Fall Il Other ID Retardant /Accelerator (name) <br />in I )11% a <br />PUMP ?I Submersible 0 Turbine 0 Other HP II 13-- Pump Set V SVi) ft Standing Water Level ‘k (0 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 /> <br />Application Accepted By 2---/— Date q/WaRe Area L//99 Employee ID# jfl <br /> <br />Grout Inspection By <br /> <br />Pump Inspection By 37/47d6i ?P121, Date / OA <br />ft <br />PE <br />Codes <br />SC <br />Info <br />Received <br />By <br />Check#/ Amount Date Permit/ <br /># Invoice # Well ID# <br />i-138,1 0 ..-0 <br />.vr94....... 477itted 1_01. 2.1 vleprv6511R .tqiiz t <br />. . <br />I <br />PEDESTAL Installed By 0 Driller 0 Pump Contractor 0 Other <br />Concrete Pedestal 0 Dimensions: Width ft Length <br />0 Christy Box Stove Pipe <br />0 SPECIAL Well Permit <br />Li WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth <br />COMMENTS Poe ukvieit coo f cif n /yos tvi <br />ft Thick : seaticiay giis Z6?"11 2/P <br />EHD043-06 10/25/2021 Well / Pump Pamit