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PUMP ,,,Nctubmersible:l Turbine 2 Other <br /> <br />HP Pump Set ‘,..15 .0 ft Standing Water Level \ \ CD ft <br /> <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 UCENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION <br />C <br />i0 ANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (2t1Pl PS:3-78C— <br />SIGNED , ) <br />TITLE ct14, DA. 1-/-11( 2( <br />JOB ADDRESS 13 ncn N Al pine Rd Crn'arpLodi , CA 95240 <br />cposs STREET E Handel Rd ApN 06306011 PARCEL SIZE 20 LAND USE APPLICATION # <br />OWNER NAME Northwind Farms PHONE <br />OWNER ADDRESS 8400 E Handel Rd crrriSTATEmpLodi , CA 95240 <br />CONTRAcTOR Purviance Drillers, INC pHoNE 209-887-3554 <br />CONTRACTOR ADDRESS P 0 Box 64 <br />SUBCONTRACTOR/CONSULTANT <br />cmds.ThrEizip Linden CA 95236 <br /> <br />PHONE <br /> <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br /> <br />CrryISTATFJZip <br /> <br />UCENSE 5-c C-57 C-61 Li D-09 '2, Other NUMBER 377923 E)CPIRATION DATE 7/31/21 <br />BILLING PARTY: OWNER E CONTRACTOR Li SUBCONTRACTOFtiCONSULTANT <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAIELTON AVENUE -S-roctcroN CA 95205 -6232 (209) 468-3420 <br />NON-REFUNDABLE PERMIT www.sjgov.orgiehd EXPIRES 1 YEAR FROM DATE ISSUED <br />DomEs-nc WELL SAMPLING: f General Mineral/Coliform Bacteria (4391)7] Dibromochloropropane (4392) D Arsenic (4393) <br />INTENDED USE Li Domestic/Private )4rrigation/Agricultural Li Industrial 2 Water Quality Monitoring Li Soil Sampling/Characterization <br />Public Water System <br />If different front Owner. Water System Name Contact Name or Mona Number <br />TYPE OF WORK Li New Well Li Replacement Well L: Well Alteration/Modification L." Other <br />2 Monitoring Well(s) # of wells '.' Soil Boring(s) # of borings -.: Geotechnical 1 of borings <br />.2, Out-Of-Service Well LI Out-Of-Service Well Renewal El Cross-Connection Repair <br />El, New Pump •KPump Replacement L1 Pump Repair El Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method El., Mud Rotary I'. Air Rotary I] Auger 71 Cable Tool El, Push Point Cl Other <br />Proposed Well Depth ft Excavation in diameter :I Open Bottom D Gravel Pack/Gravel Size in diameter <br />"J Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter In Thicicness/GaugelASTM Sched ll Steel Cl Plastic n Stainless Steel J Other :333110011311S Grout Seal Depth ft Li Neat Cement (94 lb bag/5-10 gal water) Cl Sand Cement sack mixr7 gal water <br />L Bentonite (20% solids) Li Other <br />Grout Placement Method 2 Pumped J Free Fall L. Other Li Retardant / Accelerator (name) <br />Egp&s:rhk Installed By Driller 2 Pump Contractor C Other <br />Concrete Pedestal c.Dimensions: Width ft Length <br /> <br />ft Thick <br /> <br />in i; Christy Box D Stove Pipe <br /> <br />Y i <br />'v i' <br />s- . <br />D‘ree`.--- f•.,:t, .,. <br />k qJ -11! <br />: • <br />I -.:-. _ — <br />— . , i ) <br />2r _ __ 14 c“-CI. \ <br />DEPARTMENT usg ONLY <br /> <br />,f -"----74,7 2-- L-- Date id ill''4 / Area 41/(1 i t <br /> <br />Application Accepted By Employee ID# 1-.,) fi <br /> <br />Grout Inspection By Date '.1 SPECIAL Well Permit <br /> <br />Pump Inspection By jkiiire- - Date 5/2 L//20 2-4 n WAIVER Received <br /> <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />PE <br />Codes <br />SC <br />Info <br />Received Checkilt/ cash Amount <br />Remitted ! Date <br />Permit/ Invoice # Well ID# <br />t. ..: c ,.... ,._ 0 z <br />X <br />34---- 4 7 -1 v.K 1 <br />Rgielitt{:3 1/371ce <br />^ ' <br />268 n11.7 z_ <br />WELL /PUMP PERMIT