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1 WELL/PUMP PERMIT <br />SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE -STOCKTON CA 95205 - (209) 468-3420 <br />NUN -KF -FUNDABLE PERMIT CALL ZU9 953-7657 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 3008 Jacktone RD clTY/zlPStockton, CA 95215 <br />CROSS STREET St Rt Hwy 26 APN 10507007 PARCEL SIZE 9 7. 7 54 -AND USE APPLICATION <br />OWNERNAME Vernon G Gogna Partenership pF,nNF <br />OWNERADDRESS 13797 E Fanning Rd <br />CONTRACTOR Purviance Drillers, Inc <br />PO Box 64 <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR n/a <br />SUBCONTRACTOR ADDRESS <br />LICENSE IXC -57 ❑ C-61 ❑ D-09 ❑ Other <br />CITY/STATEIZIP Stockton,CA 95215 <br />PHONE209-887-3554 <br />CITY/STATEIZIP Linden, CA 95236 <br />CITYISTATE/ZIP <br />NUMVER 3 7 7 9 2 3 EXPIRATION DATE 7/ 31 / 2 3 <br />DOMESTIC WELL SAMPLING: - General MineraUCOliform Bacteria (4391) _ Dibromochloropropane (4392) - Arsenic (4393) <br />INTENDED USE ❑ Domestic/Private XIrrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Ovmer. Water System Name Contact Name or Phone Number <br />TYPE OF WORK ❑ New Well ❑ Replacement Well C Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of. borings ❑ Geotechnical <br />U Out -Of -Service Well C Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br /># of borings <br />❑ New Pump Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method C Mud Rotary ❑ Air Rotary ❑ Auger r7 Cable Tool n_ Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel SizRE� 11, diameter <br />❑ Conductor Casing in diameter 1 Conductor Casing Depth f IV VV <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel We I )CIO <br />Grout Seal Depth ft ❑ Neat Cement (94 Ib bagl5-10 gal water) G Sand Cement s6cK'4ft water <br />❑ Bentonite (20% solids) E Other COUNTv <br />Grout Placement Method ❑ Pumped ❑ Free Fall D Other ❑ Retardant /Accelerator (name) ryV12ONr'';, ;"eN; <br />M A6"� � <br />?EDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal DDimensions: Width ft Length ft Thick <br />n ❑ Christy Box ❑ Stove Pipe <br />Pump ❑ Submersible Turbine ❑ Other HP =1 Pump Set --LSD ft Standing Water Level f <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 />DEPARTMENT USE/ ONLY <br />Application Accepted By �— K� j�� Date 7/�r�/�� Area � Employee ID# <br />Grout Inspection By n ❑ SPECIAL Well Permit <br />Pump Inspection By ��J 'c�n'X!� ,'l.! Date 7r ❑ WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />T <br />PE Sc Received Check#/ <br />Codes Info B as <br />Amount <br />Remitted <br />Date Permit/ Invoice # Well ID# <br />Service Re uest# <br />I <br />I 1 <br />EHDO43-0610f1V2021 / "G � Q�u --2/% '-2, �// d Page I oft \�ellIPumpPcrmit <br />Y v lJ <br />Ito (` � �' <br />