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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468-3420 <br /> f NON-REFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> ESS <br /> JOB ADDR745 & 23649 E Harney Ln CITY/ZIP Lodi m <br /> `pre067-040-090 <br /> D <br /> CROSS STREET "�'�'` APN PARCEL SIZE y , LAND USE APPLICATION# z <br /> OWNER NAME Berghill, LLC PHONE 209-888-5465 y <br /> OWNER ADDRESS PO BOX 739 CITYISTATEIZJP Linden, CA 95236 <br /> CONTRACTOR Purviance Drillers, Inc 1H111IE209-887-3554 <br /> CONTRACTOR ADDRESS PO BOX 64 CITY/STATEIZIP Linden, CA 95236 <br /> SUBCONTRACTOR/CONSULTANT n a PHONE <br /> SUBCONTRACTOR/CONSULTANTADDRESS n/a CITY/STATEIZIP <br /> LICENSE IXC-57 C-61 _ D-09 Other NUMBER <br /> 3 7 7 9 2 3 EXPIRATION DATE 7/31 /2 1 <br /> BILLING PARTY: OWNER -CONTRACTOR SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING: _General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private Ximgation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner Water System Name Contact Name or Phone Number <br /> TYPE OF WORK )(New Well .Replacement Well Well Alteration/Modification _ Other PAytij� <br /> Monitoring Weil(s) #of wells Soil Bonng(s) If of borings Geotechnical o of borings V�7' <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair �� <br /> New Pum Pum Replacement Pum Repair Raise Well Casing //�� <br /> WELL CONSTRUCTION P O <br /> Drilling Method Mud Rotary ❑Air Rotary Auger - Cable Tool - Push Point Other 2020 <br /> Proposed Well Depth/WO ft Excavation .2.9 _in diameter X Open Bottom Gravel Pack/Gravel Size in dIa AQIJ/N U <br /> Conductor Casing N/N in diameter / Conductor Casing Depth ft N R . OUN7Y <br /> Well Casing Diameter J& in Thickness/Gauge/ASTM Schad .21'-4 XSteel Plastic Stainless Steel Other H� /VMENTA <br /> Grout Seal Dept _ft Neat Cement(94 Ib bag/5-10 gal water) y Sand Cement sack mixr7 gal water EPARTMEN)' <br /> Bentonite(20%solids) Other <br /> Grout Placement Method yL Pumped Free Fall Other _. Retardant/Accelerator(name) <br /> PEDESTAL Installed By x Driller Pump Contractor Other <br /> 11(Concrete Pedestal Dimensions:Width ft Length ft Thick in __Christy Box Stove Pipe <br /> PUMP -Submersible_Turbine Other HP Pump Set ft Standing Water Level ft <br /> 1 HEREBY CERTIFY THAT 1 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 COMPENSATIOU LAWS. <br /> iN UNI U /y�py�ANCE NOTICE REQUIRED FOR INSPECTIONS-PLEAS=C,�.I_L.1205! 53-7 97 <br /> SIGNED J"�y �- TmEC-orporate Secretad-e� <br /> 1 <br /> 1 <br /> Inn_i <br /> 01 <br /> lD <br /> DEPARTMENT USE ONLY <br /> Application Accepted By d� �1, I Date ;Q'�l) Area 9 � Employee lD# ;+�''f• <br /> Grout Inspection By /� � '— f L� Date r&' SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection Byp ,7 `t <br /> Date Constructed Well Depth ft <br /> COMMENTS �jnn c <br /> PE SC Received Amount Date Permit/ Invoice# Well ID# <br /> Codes Info Remitted ice Re uest#. <br /> EHO 43-06 6/112019 WELL/PUMP PERM17 <br />