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WELL/PUMP PERMIT <br /> f SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 27751 E Elliott Rd CITY/ZIP Galt <br /> N Jack Tone NPN 00712025 <br /> CROSS STREET PARCEL SIZE 4WLAND USE APPLICATION# z <br /> OWNER NAME Coyote Creek Farms , LLC ,ae4,r�S, LOV E209-479-8763 w <br /> OWNER ADDRESS 6464 E Live O a k Rd s)pj�,Lru ITY/STATE/ZIP Lodi , C A 9 5 2 4 0 <br /> CONTRACTOR Purviance Drillers , Inc PHONE 209-887-3554 , <br /> CONTRACTOR ADDRESS P O B o x 64 CITY/STATE/ZIP Linden , CA 95236 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP p <br /> LICENSE MC-57 C-61 UD-09 Other NUMBER Wy-3 EXPIRATION DATE-7-3149/-/'3/' 7 <br /> DOMESTIC WELL SAMPUNG:i,General Mineral/Coliform Bacteria(4391)1 i Dibromochloropropane(4392)11 Arsenic(4393) <br /> INTENDED USE DomestictPrivate Xlrrigation/Agricultural n Industrial Water Quality Monitoring i-.Soil Sampling/Characterization <br /> -i Public Water System A <br /> If different from Owner Water System Name Contact Name or Phone Number <br /> TYPE OF WORK WNew Well 1 1 Replacement Well I_Well Alteration/Modification n Other <br /> MonitoringWell(s) #of wells a SoilBoring(s) #ofborings ]_i Geotechnical #ofbodngs <br /> Out-Of-Service Well n Out-Of-Service Well Renewal I i Cross-Connection Repair ` <br /> I.New Pump I I Pump Replacement u Pump Repair I,,Raise Well Casing <br /> �ZO <br /> WELL CONSTRUCTION 1 ,7 <br /> Drilling Method M Mud r'-:a- I i Air Rotary 7 Auger r able Tool I I Push Point D Other `� Q� 018 <br /> Proposed Well Depth—tD��ft 3- Excavation !y i�Z in diameter X Open Bottom Gravel Pack/Gravel Size In qty FNM CSV <br /> Conductor Casing in diameter / Conductor Casing Depth ft r/Y Fop <br /> Well Casing Diametter_ in Thickness/Gauge/ASTM Schad •2�Q Steel Plastic Stainless S I`Other M rC <br /> Grout Seal Dept 1Y itt ft Neat Cement(94 Ib bag/5-10 gal water) ?(Sand Cement 10 sack mixl7 gal water FNT <br /> Ben onite(20%solids) I Other <br /> Grout Placement Method Pumped 'i Free Fall r:Other i i Retardant/Accelerator(name) <br /> PEDESTAL Installed By i Driller I Pump Contractor I Other <br /> Concrete Pedestal i]Dimensions:Width ft Length ft Thick in i i Christy Box i I Stove Pipe <br /> PUMP a Submersible I Turbine r i Other HP Pump Set ft Standing Water Level ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINI M 48 HO A A E NOTJCE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953--77669`7 <br /> SIGN TITLE Corporate SecretaT'Att <br /> J <br /> 11 t <br /> PA FYT M E N T UJS E Q1 NLIJ <br /> Application Accepted By ,V Nill <br /> il Date Area Employee ID#� <br /> Grout Inspection By 4 Date C SW@II Permit <br /> Pump Inspection By Date F1 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes fo a ed Seryice Re uest# <br /> EHD 43-06 revised 4/14/18 WELL/PUMP PERMIT <br />