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' WELUPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 4683420 <br />-KEFUNDABLE <br />EXPIRES 1 YEAR FROM DATE <br />JOB ADDRESS 256(11 St Rt HWy 26 crry/7iP Linden,CA 95236 <br />CROSS STREETESCalon Bellota Rd APN 06719013 <br />j� Fy PARCEL SIZE MLLAND USE APPLICATION # <br />OWNER NAME D & L FarInS +� SL- Fx--.�' ►i7 .i il�/.s LLC PHONE <br />OWNERADDRESS P -O- BOX 620 CITY/STATE/2:IP Linden,CA 95236 <br />CONTRACTOR Purviance Drillers, INC PHONE209-887-3554 <br />CONTRAcTORADDRESSP-O- BOX 64 CITY/STATE/Z,pLinden CA 95236 <br />SUBCONTRACTOR/CONSULTANT <br />SUBCONTRACTORICONSULTANT ADDRESS <br />LICENSE X C-57 '; C-61 ii D-09 <br />BILLING PARTY: OWNER <br />CITYISTATE21P <br />I Other NUMBER 377923 <br />G CONTRACTOR C SUBCONTRACTOR/CONSULTANT <br />PHONE <br />EXPIRATION DATE 7/31/23 <br />DOMESTIC WELL SAMPLING: 1: General Mineral/Coliform Bacteria (4391) 17 Dibromochloropropane (4392) G Arsenic (4393) <br />INTENDED USE Domestic/Private�Irrigation/Agricultural Industrial -_Water Quality Monitoring ❑ Soil Sampling/Characterization <br />_ Public Water System <br />If different fmm Owner. Water System Name Contact Name or Phone Number <br />rx— wen L meplacemem Well ,; Well Alteration/Modification ❑ Other <br />C Monitoring Well(s) Of wells :1 Soil Boring(s) it at borings G Geotechnical of borings <br />D Out -Of -Service Well Out -Of -Service Well Renewal G Cross -Connection Repair <br />�? New Pumn d Pmmn Rcnloromnnr c D,,..,., De ;. . o_.__ <br />Drilling Method '' Mud Rotary r; Air Rotary ❑ Auger Cable Tool Push Point _ Other <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom G Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched Steel E� Plastic 'I Stainless Steel i I Other <br />Grout Seal Depth ft Neat Cement (94 Ib bagl5-10 gal water) Sand Cement sack mixl7 gal water <br />Bentonite (20% solids) :1 Other <br />Grout Placement Method Pumped G Free Fall 11 Other Retardant /Accelerator (name) <br />PEDESTAL Installed By '-- Driller Pump Contractor L Other <br />.: Concrete Pedestal _:Dimensions: Width It Length ft Thick in I' Christy Box ❑ Stove Pipe <br />PuMP Submersible Turbine - Other HP =L Pump Set ft Standing Water Level ft <br />1 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 LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />T <br />m <br />D <br />0 <br />A <br />a <br />DEPARTMENT USE ONLY <br />Application Accepted By '—­7Z;:�� �- Date /7i Area L4 �� C Employee ID#FG <br />Grout Inspection By A Date 'I SPECIAL Well Permit <br />Pump Inspection By Date 7 D WAIVER Received <br />Soil Boring Inspection By Date --� Constructed Well Depth tt <br />COMMENTS ik f , ( "t' I I me ° - bPy 1'1/. 7[aY( J! a'� yr�C.�f'J �� /c I <br />� /F' Pl1 �r�1��lr/r <br />r r, )> 1t y s h:r.tif o e( <br />PE SC Received Check#/ <br />Codes Info ash <br />Amount Permit/ <br />Remitted ate Service Re u st # Invoice # Well ID# <br />i 3Y o <br />7 - c, , <br />I <br />-77I6 <br />�••V _w� V„I�v,a 133 WELL/PUMP PERMR <br />Y <br />,��IFNT <br />�F16 <br />c <br />ti°�Hry <br />7� Qt NT <br />