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WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)4683420 <br /> NON-REFUNDABLE PERMIT WWW.s ov.Or /ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 20601 E Kettleman Ln cm,/LP Lodi Ca 95240 <br /> M <br /> CROSS STREET / .] C <br /> —Cl cm o n t-c R r7 APN V I 1 L) r][ PARCEL SIZE -- LAND USE APPLICATION# O <br /> 0 <br /> OWNER NAME Boe hinct Tre land Farms INC PHoNE209-7273471 <br /> OWNER ADDRESS Lona Valley Rd CITY/sTATEOpWoodland Hills CA 91367 <br /> CONTRACTOR Purviance Drillers, INC PHONE209-887-3554 <br /> CONTRACTOR ADDRESS P-0- BOX 64 cln./STATEMPLinden CA 95236 <br /> SUBCONTRACTORICONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS QTY/STATE/LP <br /> LICENSE R C-57 C-61 !D-09 Other NUMBER 377923 EXPIRATION DATE 7/31/21 <br /> BILLING PARTY: _OWNER CONTRACTOR L, SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:G General Mineral/Coliform Bacteria(4391)C Dibromochloropropane(4392)t Arsenic(4393) <br /> INTENDED USE Domestic/Private Irrigation/Agricultural '- Industrial ;:Water Quality Monitoring C Soil Sampling/Characterization <br /> Public Water Sy em <br /> lfdlifeme t from Ovmer Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ;;New Wel! C Replacement Well :,Well AlteratioNModification C Other <br /> Monitoring Well(s) #of wells C Soil Boring(s) tf of borings it Geotechnical x of bongs <br /> Out-0f-Service Well Out-OfService Well Renewal ^.Cross-Connection Repair <br /> New Pump XPumpReplacement L Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ;: Mud Rotary :1 Air Rotary 'I Auger Cable Tool C Push Point I Other <br /> Proposed Well Depth ft Excavation in diameter :1 Open Bottom 1 Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched l Steel :-Plastic n Stainless Steel -i Other <br /> Grout Seal Depth ft -:Neat Cement(94/b bag15-10 gal wafer) -r�Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) ❑Other <br /> Grout Placement Method -�Pumped i Free Fall C Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By _Driller Pump Contractor L' Other <br /> (_:Concrete Pedestal,Dimensions:Width ft Length It Thick In 7,Christy Box C Stove Pipe <br /> PUMP Submersible Turbine =Other HP p e X90 -s <br /> tee- g Water Level ./,Sft <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. 1 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 /> WORKERS COMPENSATI WS. <br /> �11 'ANC-9Y Nn_T!Cc <br /> SIGNE y <br /> TITLE ..^DATE <br /> FC MENT <br /> F�AFD <br /> y zo?o <br /> QU/N <br /> FPq T��NT� <br /> KENT <br /> DEPARTMENT USE ONLY <br /> Application Accepted By L� Date ✓- r� Area / Employee ID# (( <br /> Grout Inspection By Date I SPECIAL Well Permit <br /> Pump Inspection By ::,.�L,S I c L- Date t <br /> ,A Zl-�I!=�=' WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth it <br /> COMMENTS <br /> PE SC Received Check#/ Amount Permit/ <br /> Codes Info Cash Remitted Date ervice est# Invoice# Well ID# <br /> RA`Y..: ! <br /> EHD 43-06 5/17!2019 WELL/PUMP PERMIT <br />