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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (269) 466-3420 <br />NON-REFUNDABLE PERMIT WWW.S Ov.Or/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />JOBADDRESS 17071 E Raker Rr1 CtTY/Zip Linden,CA 95236 <br />CROSS STREET p rrh aryl ^ 1 e Rr9 APN ��r I� PARCEL SIZE / eit L/ <br />LAND USE APPLICATION # <br />OWNER NAME F'prrari Fa rmc 7n[• PHONE <br />OwNERADDRESS 17D71 F Raker Rd CITY/STATEMP Linden,CA 95236 <br />CONTRACTOR Purviance Drillers INC PHONE209-887-3554 <br />CONTRACTOR ADDRESS P- 0- BOX 64 CrrYISTATE/ZIPL i nden CA 95236 <br />SUBCONTRACTOR/CONSULTANT <br />PHONE <br />TANT ADDRESS <br />LICENSE k C-57 C C-61 :i D-09 <br />BILLING PARTY; OWNER <br />DOMESTIC WELL SAMPLING: C General Mir <br />INTENDED USE :: DOmesf CIPtivate ' �Irrig <br />Public Water Syst m_ <br />H dMemnt from Owner <br />CITY/STATE/ZIP_ <br />Other NUMBER 377923 <br />CONTRACTOR :i SUBCONTRACTOWCONSULTANT <br />EXPIRATION DATE 7/31/23 <br />Bacteria (4391) tI Dibromochloropropane (4392) G Arsenic (4393) <br />tl :] Industrial ❑ Water Quality Monitoring U Soil Sampling/Characterization <br />TYPE OF WORK r_; New Well C Replacement Well ❑ Well Alteration/Modification Ci Other <br />D Monitoring Well(s) # Of wells ':Soil Borings) a of bodngs ❑ Geotechnical <br />D Out -Of -Service Well C Out -Of -Service Well Renewal Cross -Connection Repair <br />C New Pump •IWump Replacement - Pump Repair - R <br />WELL CONSTRUCTION arse Well Casmg <br />N of borings <br />N <br />Drilling Method Mud Rotary Air Rotary Auger C Cable Tool 1,' Push Point ' Other Sq N JOq <br />Proposed Well Depth k Excavation in diameter ❑ Open Bottom G Gravel Pack/Gravel Size V1♦ <br />I <br />i1 Conductor Casing in diameter -/Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Schad f- Steel -1 Plastic ❑Stainless Steel Other <br />Grout Seal Depth ft Neat Cement (94 Ib bag/5 10 gal water) C Sand Cement <br />sack mlx/7 gal water <br />Bentonite (20% solids) U Other <br />Grout Placement Method Pumped l: Free Fall ❑ Other ;; Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor ! Other <br />Concrete Pedestal GDimensions: Width It Length It Thick in :Christy Box Stove Pipe <br />PUMP �Submersihle _' Turbine "Other HP o c ''l >, <br />r acanamg water Level l V`-1' g <br />1 HEREBY CERTIFY THAT I NAVE 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 CONTRAC70RS STATE LICENSE BOARD AND THAT I AM IN COMPLUWCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />urt ArtTMENT USE ONLY <br />Application Accepted By I— -I. Date J /Y .� / Area D "% Employee ID# _ <br />Grout Inspection By A Date :1 SPECIAL Well Permit <br />Pump Inspection By Date K ( Z ❑ WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS If I ' �Y' yJ P.l t�nrt f c c' > 1 <br />L /� <br />'f i 7 Y r� LILY 1� lC: l i -� /'. ,fit. ' " " . i.,.., j _ \ <br />Info <br />^^'� <br />�.J V <br />EHD 43-06 611112019 <br />T <br />D <br />O <br />A <br />N <br />Invoice # I Welt ID# <br />