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I WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 465-3420 <br />NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOBADDRESS 1501 Hollenbeck Rd CITY/ZIP_Stc)r_ on,CA 95215 <br />CROSSSTREET S, Hollenbeck Rd ApN 18317001 PARCEL SIZE 55. LAND USE APPLICATION# <br />OWNER NAME Ha i vu Gong PHONE 209 9 81 8518 <br />OWNERADDRESS __1501 Hollenbeck Rd CITY/STATE2IP Stockton,CA 95215 <br />CONTRACTOR Purviance Drillers, Inc PHONE209-887-3554 <br />PO Box 64 Linden, CA 95236 <br />CONTRACTOR ADDRESS CITY/$TATE/ZIp <br />SUBCONTRACTOR n/a <br />PHONE <br />SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br />LICENSE )Q(C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER 377923 EXPIRATION DATE -3-J-3 1 / 2 3 <br />DOMESTIC WELL SAMPLING::-. General Mineral/Coliform Bacteria (4391);' Dibromochloropropane (4392) _' Arsenic (4393) <br />INTENDED USE ❑ Domestic/Privaterngation/Agricultural ❑ Industrial 11 Water Quality Monitoring ❑ Soil Sampling/Characterization <br />EJPublic Water Syste <br />If different from Owner. Water System Name Contact Name or Phone Number <br />TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br />❑ Monitoring Wells) # of wells ❑ Soil Boring(s)# of borings ❑Geotechnical <br />❑ Out -Of -Service Well Out c -y <br />❑ -Of -Service Well Renewal ❑ Cross -Connection Repair c �' <br />C` <br />❑ New Pum Pum Re lacement ❑Pum Re air ❑ Raise Well Casing�~ <br />7W— / <br />WELL CONSTRUCTION t <br />n <br />!"� <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary El Auger ❑ Cable Tool ❑ Push Point ❑ Other Sn <br />4 ?�%i <br />Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑ Gravel Pack/GraveJ � 4 �I diameter <br />11 Conductor Casing N <br />in diameter / Conductor Casing Depth ft q� N 00 <br />FNr <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other F /ART 'I NTY <br />Grout Seal Depth ft ❑ Neat Cement (94 /b bag/5-10 gal water) ❑ Sand Cement sackmix 9aitdater <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ 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 ❑ SubmersiblkTurbine ElOther HP Pump Set ft Standing Water Level <br />Plot Plan Requirements. ttach 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 />t . ;� 't I is 1: r r.- _ .. <br />ii. t13�t'1")I �. ti],'+ r 7 e .x. '1 _a.'d)I�tl;:i'`.."+ <br />DEPARTMENT USE ONLY <br />Application Accepted By -f'— Date Area_!t/ ��i <br />Employee ID# / r� <br />Grout Inspection By ate ❑ SPECIAL Well Permit <br />Pump Inspection By Date❑ WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />PE SC Received Check#/ Amount Permitl <br />Codes Info B Cash Remitted Dat Service Re uest # Invoice # <br />Well ID# <br />-43-0. 10/25/2021 f�42 t�� <br />