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I WELL/PUMP PERMIT <br />SAN-iOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />fVON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 24125 E St Rt Hwy 26 <br />clnr/zIPinden CA 95236 <br />CROSS STREET Escalon Bellota RDpPN 09135019 <br />OWNER NAME Tom Watkins PARCEL SUE 5.82 <br />LAND USE APPLICATION # <br />PHONE209 6077880 <br />OWNER ADDRESSP--LL $n}{ 86 <br />CONTRACTOR Purviance Drillers Inc <br />CONTRACTOR ADDRESSP <br />O BOX 64 <br />SUBCONTRACTOR n/ a <br />SUBCONTRACTOR ADDRESS <br />LICENSE XW 57 ❑ C-61 ❑ D-09 ❑ Other <br />CITY/STATEOP L-inden CA 95236 <br />PHONE209-887-3554 <br />CITY/STATEMP Linden, CA 95236 <br />PHONE <br />CITY/STATEIZIP <br />NUMBER 377923 EXPIRATION DATE 7/ 31 <br />DOMESTIC WELL SAMPLING: �--' General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) El Arsenic (4393) <br />INTENDED USE Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterizati <br />❑ Public Water System on <br />If different from Owner. Water System Name <br />Contact Name or Phane Number <br />TYPE O WWORE( ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br />❑ Monitoring Wells) # of wells ❑ Soil Borings) # of borings <br />❑ Out -Of -Service Well ❑Geotechnical ?gprj,'n9s <br />❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair Qc��yy GYM A f <br />❑ New Pum '$$pump Replacement ❑ Pump Repair ❑Raise Well Casing ' `` G'�r, �, y T <br />WELL CONSTR CTION <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cabl6 Tool ❑ Push Point ❑ Other On <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft EP C/1 In tel <br />Gr Casing Diameter in Thickness/GaugelASTM Sched <br />V/ N <br />Grout Seal Depth ft ❑Steel ❑Plastic ❑ Stainless Steel yp pt;1* 41E/COVNTy <br />❑ Neat Cement (94 Ib bag/5-10 gal water) ❑ Sand Cement. <br />❑ Bentonite (20% solids) ❑ Other -sack m- r <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other <br />❑ Retardant /Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑Pump Contractor ❑ Other <br />In <br />❑ Concrete Pedestal ❑Dimensions: Width ft Length ft Thick <br />❑ Christy Box ❑ Stove Pipe <br />PUMP Submersible❑ Turbine ❑ OtherHP It p �r Pum Set <br />PIot Plan Requirft Standing Water Level <br />ements: Attach a plot pian with the exact location of water well with respect to the following ft <br />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 />;�srf 1:, <br />DEPARTMENT USE ONLY <br />Application Accepted By �,v- Date `/ v�. <br />Grout Inspection By A Date <br />Pump Inspection By X1 IDate <br />Soil Boring Inspection By Date <br />:OMMENTS , s <br />odes I Info <br />Sw <br />Amount <br />C%L- / <br />Area i ��; <br />Employee ID# -J4 <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth <br />LC! 5 4- -1-, r ,?i <br />Invoice # <br />Well ID# <br />D03;-06 10h;ho2i �/ ,6 <br />/I 2—/)�40 Page 1 oft <br />T `ATO/ <br />ft <br />