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JOB ADDRESS 6487 N Cox Rd cm/zip T, ndPnCA 923E <br />OWNER NAME 0 & G Ranch - TY)( 117) <br />OWNER ADDRESS 6697 N_ Cox Rd <br />Purviance Drillers, INC CONTRACTOR PHoNE 20 9-887-3554 <br />CITY/STATE/ZIPLinden CA 95236 <br />PHONE <br />CITY/STATE/ZIP <br />SUBCONTRACTOR/CONSULTANT <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />CONTRACTOR ADDRESS P•O• Box 64 <br />CONTRACTOR SUBCONTRACTOR/CONSULTANT BILLING PARTY: Li OWNER <br />Installed By 7_," Driller Pump Contractor L Other <br />:_. Concrete Pedestal =Dimensions: Width ft Length ft Thick <br />PEDESTAL <br />III Christy Box E Stove Pipe <br />SIGNED 'N0:110E REQUiRED FOR . :3 - PLEASE CALL (209) G53-7-Frr <br /> Trri_EOct kl;‘) 14-O rP DATE /2-- / <br />crc` <br />uvg <br />- Ilgo 12_2_ WEU_ /PUMP PERMIT <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCiCrON CA 95205 -6232 (209) 468-3420 <br />NON-REFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />DOMESTIC WEU_ SAMPLING: r: General Mineral/Coliform Bacteria (4391) i-1 Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE L Domestic/Private skrrigation/Agricultural IT Industrial Water Quality Monitoring LI Soil Sampling/Characterization <br />= Public Water System <br />If different from Owner: <br />TYPE OF WORK . New Well IL Replacement Well Li Well Alteration/Modification . Other <br />7. Monitoring Well(s) # of wells 7: Soil Boring(s) # of borings i'. Geotechnical fr et borings <br />.:. Out-Of-Service Well II Out-Of-Service Well Renevical E Cross-Connection Repair <br />i: New Pump - Pump Replacement )(Pump Repair '",-.x..1,--eXt.oi., III Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method ... Mud Rotary :I Air Rotary Li Auger r: Cable Tool ..; Push Point I.:I Other <br />Proposed Well Depth ft Excavation in diameter El Open Bottom = Gravel Pack/Gravel Size <br />E Conductor Casing in diameter I Conductor Casing Depth ft <br />Well Casing Diameter in ThIckness/Gauge/ASTM Sched IL Steel 11 Plastic Ii Stainless Steel El Other <br />Grout Seal Depth ft :: Neat Cement (94 lb bag/5-10 gal water) <br />L Bentonite (20% solids) Li Other <br />Grout Placement Method -i Pumped 7 Free Fall Li Other <br />PUMP SubmersibleXTurbihe L- Other HP O Pump Set 9400 ft Standing Water Level \CA,c7 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 C ORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />\A_ <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />PE <br />Codes <br />SC <br />Info <br />Received Checill <br />. )ash <br />Amount <br />Remitted Date Permit/ <br />Service Regugst # Invoice # Well ID# <br />' 1// 7 a,' 2-710 trt P00 44 ‘ 59 Li <br />— A W., , <br />FR <br />ft <br />--a <br />Date <br />Date Vi -7/X1 01 <br />Date <br />DEPARTMENT USE ,ONLY <br />Date 1.7//1/2J t-A Area Employee ID# <br />SPECIAL Well Permit <br />1 WAIVER Received <br />Constructed Well Depth <br />Water System Name <br />Retardant / Accelerator (name) <br />E Sand Cement <br />Contact Name or Phone Number <br />sack mix/7 gal water <br />in diameter :SS3110CIV 311S r , CROSS STREET Baker RD APN 09124047 PARCEL SIZE :f LAND USE APPLICATION # <br />LICENSE R. 0-57 Li 0-61 = 0-09 Li Other NUMBER 377923 EXPIRATION DATE 7/3 1 /2 1 <br />PHONE <br />CITY/STATE/ZIP T. i nden,rA 9523A