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A <br />1 WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />..v —N=N vlYVNOLC r=KMI I <br />ADDRESS 18800 Frazier Rd <br />GALL iZUV) V53-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />crry/ztP Linden, CA 95236 <br />CROSSSTREET Clements RD APN 0651 501 1 <br />PARCEL SIZE 3 9 .3 3 -AND USE APPLICATION # <br />OWNERNAME Prieto/Wolf Frazier RD PHONE <br />OWNERADDREs3 249 Royal Oaks Ct CITY/STATE21P Lodi ,CA 95240 <br />CONTRACTOR Purviance Drillers, Inc PHONE209--887-3554 <br />CONTRACTOR ADDRESS O Box 64 Linden, CA 95236 <br />CITY/STATE/ZIP <br />SUBCONTRACTOR n/a <br />SUBCONTRACTOR ADDRESS CiTY/STATE21P <br />LICENSE }Q�C-57 ❑ G-61 ❑ D-09 ❑ Other NumRER 3 7 7 9 21 <br />PHONE <br />EXPIRATION DATE <br />DOMESTIC WELL SAMPLING: - General Mineral/Coliform Bacteria (4391) i= Dibromochloropropane (4392) ❑ Arsenic (4393) <br />INTENDED USE ❑ Domestic(Private Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Owner. <br />Water System Name Contact Name or Phone Number is <br />TYPE Or- WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings ❑ Geotechnical <br />- fOutOf-Service&II ❑ Out-OfSeri ice Well Renewal ❑ Cross -Connection Repair <br />11AY <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary 0 Auger ❑ Cable Tool ❑ Push Point ❑ Other ENV q QU/N <br />Proposed Well Depth It Excavationin diameter u Open Bottom ❑ Gravel Pack/Gravel Size N Fr(V-Lj <br />&r <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft� T DENT <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic 0 Stainless Steel ❑ Other <br />Grout Seal Depth ft ❑ Neat Cement (94 lb bag'5-10 gal water) ❑ Sand Cement sack mW/7 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped ❑ Free Fail ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal ❑Dimensions: Width ft Length ft Thick <br />in ❑ Christy Box ❑ Stove Pipe <br />PUMP ❑ Submersible Turbine ❑ Other HP_1 Pump Set U ft Standing Water Level l ft <br />Plot Plan Requirements: Atiach 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 / t. <br />Application Accepted By Date Area / Employee ID# F_ r rjo K <br />Grout Inspection By 4 A4Date ❑ SPECIAL Well Permit <br />Pump Inspection By Date f. �Z ❑ WAIVER Received <br />Soil Boring Inspection By Date 1 Constructed Well Dep ft <br />COMMENTS_1,1P llyelm i t W Po oy d3$Sv bpCt/ le ,t f`- rodrellrt44er OC&LJ1. <br />PE <br />Codes <br />SC Received Check#/ <br />Info By Cash <br />Amount <br />Remitted Data <br />Permit/ <br />Servi Request # Invoice # Well ID# <br />y38o <br />s� - <br />EHDO43-0610/SP_0_'1 — � `9 Pagel ora Nell/Pump Permit <br />T <br />