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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />�avn-ncrurvuMOLC rCFCmI I WWW <br />JOB ADDRESS 30222 N Mackville Rd <br />CROSSSTREJ,�berty Rd <br />APN 0091 7009 <br />OWNERNAME VVista Del Sol Vineyards <br />OWNER ADDRESS - BOX 1743 <br />CONTRACTOR Purviance Drillers, INC <br />CONTRACTOR ADDRESS P.O. BOX 64 <br />SUBCONTRACTOR/CONSULTANT <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />LLC <br />LICENSE X C-57 C-61 D-09 Other <br />BILLING PARTY: ❑ OWNER CONTRACTOR <br />ltd EXPIRES 1 YEAR FROM DATE ISSUED <br />CITY/ZIP 61ll(-l` - , )tI , CA 95220 <br />_PARCEL SIZE J LAND USE APPLICATION # <br />PHONE 209-462-3433 <br />CITY/STATE/ZIP Lodi, CA 95241 <br />PHONE209-887-3554 <br />CITY/STATE/ZIPL i n d e n CA 95236 <br />PHONE <br />CITY/STATE/ZIP <br />NUMBER 377923 EXPIRATION <br />SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: F General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) C; Arsenic (4393) <br />7/31 /23 <br />NTENDED USE -i Domestic/Private _K Irrigation/Agricultural Industrial ❑ Water Quality Monitoring il Soil Sampling/Characterization <br />Public Water System <br />If different from Owner Water System Name Contact Name or Phone Number <br />1 yVt: Vt- VVUKK INew weii L. rteplacement Well --- Alteration/Modification Other <br />7 Monitoring Well(s) # of wells ❑ Sail Boring(s) # of borings Geotechnical # of borings <br />D Out -Of -Service Well ❑ Out -Of -Service Well Renewal Cross -Connection Repair <br />❑ New Pump ❑ Pump Replacement ❑ Pump Repair Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method XMud Rotary ❑ Air Rotary Auger - Cable Tool _ Push Point Other <br />Proposed Well Depth i- ft Excavation 4: in diameter Open Bottom 1 Gravel Pack/Gravel Size in diameter <br />Conductor CasingJ- in diameter / Conductor Casing Depth ft <br />Well Casing Diameter L in Thickness//Gauge/ASTM Schad r ZST Steel >: Plastic 1 Stainless Steel i Other <br />Grout Seal Depth /OD ft Neat Cement (94 Ib bag/5-10 gal water) '7CSand Cement 103 sack mix/7 gal water <br />Bentonite (20% solids) D Other <br />Grout Placement Method X Pumped __ Free Fall C Other Retardant / Accelerator (name) <br />PEDESTALnstalled By X Driller - Pump Contractor Other <br />Concrete Pedestal Dimensions: Width �F ft Length ft Thick in Christy Box Stove Pipe <br />PUMP Submersible Turbine Other HP Pump Set ft Standing Water Level 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 CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />SIGNED \ l� _ uLLG 4s'ncTITLE �*T/i1/� �%�? DATE 1 0 / 1 1 / 21 <br />D E P A R T M ENT USE ON LY 1'^r� /J:!T, Y <br />14 <br />Application Accepted By i GL,, Date J / % Area f Employee ID#�T <br />Grout Inspection By Date I1 1 C1 SPECIAL Well Permit <br />Pump Inspection By ` Date ❑ WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS ��Fb-ZfCn}� Ft V m f ))fE�F'(�I C,r fJUiMy1. <br />T <br />M <br />D <br />O <br />v <br />z <br />M <br />y <br />N <br />PE <br />Codes <br />SC Received <br />Info B <br />heck# Amount <br />Cash Remitted <br />Dat <br />Permit/ Invoice # <br />Service R ueSt # <br />Well ID# <br />LI3�� <br />Fo <br />LI J <br />Ir � <br />r,iJ <br />EHD 43-06 6/11/2019 <br />WELL /PUMP PERMIT <br />