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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN-KEFUNDABLE PERMIT CALL (ZU9) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />.IOSAODREss 31000 E Wimer Rd clTy/zIP Linden,CA 95236 <br />CROSS STREET N Shelton Rd APN06731007 PARCEL SzE24.24LAND USE APPLICATION ; <br />OWNERNAME Clarence Wimer PHONE2098873380 <br />OWNERADDRESs 31000 E Wimer Rd CITY/STATEIZIP Linde CA----9-5-23-6— <br />CONTRACTOR Purviance Drillers, Inc PHONE209-887-3554 <br />PO Box 64 Linden, CA 95236 <br />CONTRACTOR ADDRESS CITYISTATEIZIP I <br />SUBCONTRACTOR n/ a <br />SUBCONTRACTOR ADDRESS <br />LICENSE y,-57 E C-61 D D-09 D Other <br />PHONE <br />CITYISTATFIZIP <br />NUMBER 3 7 7 9 2 3 EXPIRATION DATE 7/ 31 / 2 3 <br />DOMESTIC WELL SAMPLING_ - General Mineral/Coliform Bacteria (4391) _ Dibromochloro propane (4392)- Arsenic (4393) <br />INTENDED USE omestic/Private D Irrigation/Agricultural C Industrial D Water Quality Monitoring E Soil Sampling/Characterization <br />D Public Water System <br />I if different ircm Ovmer. Water System Name Contact Name or Phone Number <br />TYPE OF WORK C New Wel! " Replacement Well C Well Alteration/Modification ❑ Other <br />C Monitoring Well(s) r of wells G Soil Boring(s) of borings C Geotechnical <br />D Out -Of -Service Well = Out -Of -Service Well Renewal ❑ Cross -Connection ReDair <br />G New Pumpump Replacement C Pump Repair C Raise Well Casing q[f —n _v <br />WELL CONSTRUCTION <br />Drilling Method = Mud Rotary D Air Rotary i? Auger Cable Tool 5 -Push Point C Other E Jp,q <br />Proposed Well Depth _ ft Excavation in diameter Open Bottom C Gravel Pack/Grave N r. <br />G Conductor Casing in diameter I Conductor Casing Depth TM <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched D Steel C Plastic D Stainless Steel - Other FNT <br />Grout Seal Depth- Neat Cement (94 Ib bag/5-10 gal water) n Sand Cement sack mW7 gal water <br />Bentonite (20% solids) D Other <br />Grout Placement Method - Pumped ❑ Free Fall D Other D Retardant / Accelerator (name) <br />(PEDESTAL Installed By G Driller u Pump Contractor Other , <br />C Concrete Pedestal _Dimensions:Width ft Length ftThick I <br />jin D. Christv Box C Stove Pipe 1 <br />PUMP ubmersibieo Turbine a Other HPori Pump Set ft Standing Water Level 1 � i` -•r ft <br />Plot Pian Req irements: 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 tines. For Domestic. <br />Agriculture, Industrial well, provide location of any water wells or surface water within 200' radius of proposed well. <br />:...-._.. __...._ _ .._. ,. ,. .,,_._ _._._, _.__ -• _ __.. _... ;s-�:.__...._ ..°�e..i.t'-i}=3/95x= <br />EIRARTMENT US ONLY <br />1 <br />Area G�"_{=1_ Employee ID-y0 <br />E: SPECIAL Well Permit <br />Ll WAIVER Received <br />Constructed Well Depth ft <br />U <br />M <br />D <br />PE I SC Received <br />Co Info B <br />Check#/ <br />Cash <br />Application Accepted By <br />Date <br />Grout Inspection By A <br />I Date <br />Pump Inspection By f" <br />Date <br />Soil Boring Inspection By <br />Date <br />COMMENTS <br />I I I <br />Area G�"_{=1_ Employee ID-y0 <br />E: SPECIAL Well Permit <br />Ll WAIVER Received <br />Constructed Well Depth ft <br />U <br />M <br />D <br />PE I SC Received <br />Co Info B <br />Check#/ <br />Cash <br />Amount Permit/ <br />Invoice Well Ib <br />emitted Date Service Request <br />I I I <br />I i i <br />j <br />EHTN..3-0510';3;",2021 n Parc 1 uf_ \tell!PvmnPcrmir <br />