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4 <br />1 WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />IYvrv-KtFUNDABLE t'ERMIT <br />Jos ADDRESS 25400 S h e <br />i1 <br />CALL (209) 953-7697 FOR INSPECTIONS <br />1 YEAR FROM DATE <br />CITYZPLinden, CA 95236 <br />CROSS STREET N Go 1 more Rd APN 09318024 PARCEL SIzE 3 9 --9 CAND USE APPLICATION # <br />OWNER NAME Podesta Bros /poC%S}G. N� pGf "K-S� 11P <br />PHONE <br />OWNERADDRESS 8000 N Podesta Ln <br />CONTRACTOR Purviance Drillers, Inc <br />PO Box 64 <br />CONTRACTOR ADDRESS <br />CITY/STATEZP Linden,CA 95236 <br />PHONE209-887-3554 <br />CITY/STATE21P Linden, CA 95236 <br />n/a <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />LICENSE XZC-57 ❑ C-61 ❑ D-09 ❑ Other <br />CITYISTATE/ZIP <br />NUMBER 377923 EXPIRATION DATE <br />DOMESTIC WELL SAMPLING: ;, General MinerallColiform Bacteria (4391) _ Dibromochloropropane (4392) n Arsenic (4393) <br />INTENDED USE Domestic/Private 0 Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring 0 Soil Sampling/Characterization <br />0 Public Water System <br />If different from Owner. Water System Name Contact Name or Phone Number <br />T <br />TYPE OF WORK 0 New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s)# or borings <br />❑Geotechnical # r- T <br />0 Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />❑ New Pump 9-'P-umD Replacement ❑ Pump Repair ❑ Raise Well Casino ASA I, _ <br />S,4 /V ` T l02 <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Ca6le Tool ❑ Push Point 0 Other P PAq <br />01 <br />Proposed Well Depth ft Excavation in diameter D Open Bottom 0 Gravel Pack/Gravel Sizas qL4 _� <br />D Conductor Casing in diameter / Conductor Casing Depth ft 'C/� Tq <br />Well Casing Diameter in Thickness/Gauge/ASTMSched 0 Steel ❑ Plastic ❑ Stainless Steel ❑ Other gRTMFN <br />Grout Seal Depth It ❑ Neat Cement (94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant /Accelerator (name) <br />PEDESTAL InstallEA By ❑ Driller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal ❑Dimensions: Width ft Length ft Thick <br />in ❑ Christy Box 0 Stove Pipe <br />I au _MP Submersible❑ Turbine O Other HP <br />_L_ Pump Set ft Standing Water Level It <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 />Application Accepted By •�— a e o? �.?a <br />Grout Inspection By % (.� Date Z. <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS C,n C f m <br />►n <br />Date <br />Area y qq Employee ID# Mi <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Date Constructed Well Depth <br />ft <br />PE SC Received <br />Codes Info BY <br />Check#/ <br />Cash <br />Amount Permit/ <br />Remitted Date Service Re uest # Invoice # Well ID# <br />381 DSO <br />5� <br />7 u n , 13 <br />EHDO43-061MSl2021 W 1 Page I of 2 \Ydl / Pump Permit <br />