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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 /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 14353 Clements Rd c,Tymp Lodi , CA 95236 m <br /> 1`j z <br /> CROSS STREET PN 053-1 50—13 PARCEL SIZE� AND USE APPLICATION# o <br /> A <br /> OWNER NAME Prieto Farms, Inc. PHONE209-481 -7364 N <br /> OWNER ADDRESS 2328 Brittany Lane CITY/STATE/ZIP LCidi , CA 95240 <br /> CONTRACTOR Purviance Drillers , Inc TPHONE 209-(8'87-3554 <br /> CONTRACTOR ADDRESS P O R o x 64 CIN/STATE/ZIP L i n d e n ,C a 95236 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE iXC-57 LI C-61 I D-09 I- Other NUMBER 377923 EXPIRATION DATE 7/31/19 <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE fl Domestic/Private Irrigation/Agricultural I-.Industrial C Water Quality Monitoring []Soil Sampling/Characterization <br /> L Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK )<&ew Well []Replacement Well ❑Well Alteration/Modification D Other <br /> F1 Monitoring Well(s) #of wells ❑ Soil Boring(s) sof borings Geotechnical s or boringstrA <br /> LI Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair `4OVq�/ <br /> i New Pump F.Pump Replacement ❑ Pump Repair Raise Well Casingc <br /> WELLCONSTRUCTION 9� ^ <br /> Drilling Method)(Mud Rotary P Air Rotary -i Auger I Cable Tool -1 Push Point rl Other S ( VX 019 <br /> Proposed Well Depth &CC ft Excavation 2Z in diameter pen Bottom F Gravel Pack/Gravel Size in <br /> O <br /> I-I Conductor Casing in diameter / Conductor Casing Depth ft <br /> ( Well Casing Diameter A�in Thickness/Gauge/ASTM Sched VSteel J Plastic L Stainless Steel I Other <br /> < Grout Seal Deptft J Neat Cement(94 Ib bagi5-10 gal wa er) 4(Sand Cement 10.3 sack mix/7 gal water <br /> J Bentonite(20%solids) LI Other / <br /> Grout Placement Method Pumped []Free Fall --Other = Retardant/Accelerator(name) <br /> PEDESTAL Installed By riller []Pump Contractor I I Other <br /> Concrete P destal[]Dimensions:Wdth ft Length ft Thick in I Christy Box J Stove Pipe <br /> PUMP J Submersible[]Turbine J 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 I AM IN COMPLIANCE WITH ALL <br /> COMPEN S. <br /> IM HO R DVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIG TITLE Corpor Sectary DATE5/6/19 <br /> A <br /> U <br /> (o <br /> € 1ARTMEN7. US E Of NLY <br /> Application Accepted By r Date / Area °' Employee ID# <br /> Grout Inspection By QS 4-4` Date —Z — ❑ PECIAL Well Permit <br /> Pump Inspection By Date J WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Pepth <br /> COMMENTS /t, 1 <br /> PE Sc Received ChecW Amount Date PertntU Invoice# Well 1130Codes Info Remitted Se 'ce R uest# <br /> EHD43-06 8/01/16 WELL/PUMP PERMIT <br />