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f � <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 4683420 <br />NUN-KEFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 'I YEAR FROM DATE ISSUED <br />JOBADDRESS 1, 715 Fairchild RD CrrYlZIR. Stockton, CA 95215 <br />CROSSSTREET Beecher Rd APNO8917019 PARCELSIZE 4_ LAND USE APPLICATION# <br />OWNERNAME Nola Orchards PHONE <br />OWNERADDRESS 12525 E. Fairchild RD C"/STATE/uPStncictor,CA 95715 <br />CONTRACTOR Purviance Drillers, INC PHONE 2 0 9 — 8 8 7 — 3 5 5 4 <br />CONTRACTOR ADDRESS P. O. BOX 64 CITY/STATEIZIPL i nden CA 95236 <br />SUBCONTRACTORICONSULTANT <br />SUBCONTRACTORICONSULTANT ADDRESS <br />LICENSE j� C-57 C-61 7 D-09 it Other <br />BILLING PARTY: G OWNER F7 CONTRACTOR <br />CITYISTATE21P_ <br />NUMBER 377923 <br />G SUBCONTRACTORICONSULTANT <br />PHONE <br />EXPIRATION DATE 7 / 3 1 / 23 <br />DOMESTIC WELL SAMPLING: F . General Mineral/Coliform Bacteria (4391) J Dibromochloropropane (4392) C Arsenic (4393) <br />NTENOEo USE ❑ DomesGdPrivate gation/Agricultural Industrial Ci Water Quality Monitoring Soil Sampling/Characterization <br />Public Water Syste <br />If different from Ov er. Water System Name Contact Name or Phone Number <br />I YPE UF WORK New Well C Replacement Well 1.1 Well AlteratiorUModification ❑ Other <br />Monitoring Wells) of wells '] Soil Boring(s) #ofborinp 1 Geotechnical #of bo ngs <br />G Out -Of -Service Well G Out -Of -Service Well Renewal Cross -Connection Repair <br />J New Pump G Pump Replacement -s4Pump Repair E Raise Well Casino <br />Drilling Method C Mud Rotary C Air Rotary 7 Auger L: Cable Tool 1 Push Point 1 Other <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom L! 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 FI Plastic F Stainless Steel i I Other <br />Grout Seal Depth ft Fi Neat Cement (94 lb bag/5-10 gal water) E Sand Cement sack mW7 gal water <br />❑ Bentonite (20% solids) U Other <br />Grout Placement Method F1 Pumped Free Fall C Other Retardant /Accelerator (name) <br />PEDESTAL Installed By L: Driller _ Pump Contractor C Other <br />Concrete Pedestal ."Dimensions: Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br />PUMP _ Submersible) Turbine ❑ Other HP -LA -C2_ Pump Set O ft Standing Water Level t y2 ft <br />I HEREBY CERTIFY THAT I AVE 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 />' df NCE (j!]T[(`t; 4'EQLilj7'^0. "=fir�t-LS . PLEASE C?1..L <br />/k(91��7, 3_�c <br />SIGNED (,cw=L��L=�GUL�R-�'1Cr� • TrrLE /c.ay c� t�LllLfi, DATE <br />7 1 <br />DEPARTMENT USE ONLY �j� � i <br />Application Accepted By Date ,7 Area � Employee ID# <br />Grout Inspection ByDate '] SPECIAL Well PermitPump Inspecfion By L_ Date t j ❑ WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />y <br />m <br />D <br />mm <br />m <br />'AYMENT' <br />ECEIVED/ <br />G 0 3 2021 <br />JOAQUIN COUNTY <br />VVI HONMENTAL' <br />LTH DEPARTMENT <br />PE <br />Codest <br />Sc Received <br />Info B <br />Check#) <br />ash <br />Amount <br />Remitted at <br />Permit/IRYoICe # Well ID# <br />Service Re uest# <br />L G ,,rd <br />7 2 a <br />I <br />EHD 43-06 6/112019 I -2 A WELL (PUMP PERMIT <br />