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+ WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468-3420 <br /> NON-REFUNDABLE PERMIT www.sigov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 21433 N Devries rd CITYIZIPLodi,CA 95242 m <br /> CROSS STREET PP 1 t 1 P r Rd APN 01 3 O 2 C 1 1 D <br /> PARCEL SIZE LAND USE APPLICATION It o <br /> F <br /> OWNER NAME Fererro Vineyards INC PHONE m <br /> OWNER ADDRESS 21335 N Devries Rd CITY/STATEMP Ln C]j ,C.A 95242 <br /> CONTRACTOR Purviance Drillers, INC PNDNE209-887-3554 <br /> CONTRACTOR ADDRESS P-O. BOX 64 Cm/STATE21PL i nden CA 95236 <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE0P <br /> LICENSE R C-57 J C-61 ❑D-09 Ci Other NUMBER 377923 EXPIRATION DATE 7/31/23 <br /> BILLING PARTY: G OWNER ;CONTRACTOR C: SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:C:General Mineral/Coliform Bacteria(4391)11 Dibromochloropropane(4392)G Arsenic(4393) <br /> INTENDED USE omestic/Private ❑Irrigation/Agricultural tj Industrial -:Water Quality Monitoring I 1 Soil Sampling/Characterizabon <br /> _Public Water System <br /> If different from Ovmer. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK :,New Well C Replacement Well Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells 7 Soil Boring(S) :of borings I i Geotechnical #of borings <br /> ❑Out-Of-Service Well 'Out-Of-Service Well Renewal 0 Cross-Connection Repair <br /> ❑New Pump ::�ump Replacement _, Pump Repair C Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method :1 Mud Rotary 7 Air Rotary �Auger Cable Tool Push Point ' Other <br /> Proposed Well Depth ft Excavation in diameter 0 Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter ! Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad :Steel C Plastic ❑Stainless Steel I!Other <br /> Grout Seal Depth ft C Neat Cement(94 Ib bag15-10 gal water) ❑Sand Cement sack mix/7 gal water <br /> C Bentonite(20%solids) ❑Other <br /> Grout Placement Method S Pumped C Free Fall 0 Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By G Driller -'Pump Contractor L Other <br /> 'Concrete Pedestal'-Dimensions:Width ft Length ft Thick in r Christy Box _Stove Pipe <br /> PUMP Submersible0 Turhine Other HP Pump Set 1 H O e Standing Water Level <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 AC11VE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> 4S HOUR. ADVANCE N'OTICE 7F0(jIsFn:00r(cPt ^ 1.^,_Pt EASE CAL'.. <br /> SIGNED- JVLt/2i'!�f/1� TITLE &, 'a.!,C.� DATE <br /> qY <br /> cF��Nr <br /> Fo <br /> 2 <br /> 021 <br /> L T �N C <br /> R M�NTY <br /> FNT <br /> DEPARTMENT USE ONLY <br /> I tJ "' 15 <br /> Application Accepted By LL Date 0 1 �' Area 1 / � Employee ID# <br /> Grout Inspection By Date 1 SPECIAL Well Permit <br /> Pump Inspection By Date (l ❑ WAIVER Received <br /> Soil Boring In ion By Date Ctonstructee W�th ft <br /> C07MENTS Cam✓ 1'1$ ��,� ? t'd—�y 1.7�aG�J�. <br /> PE Sc Received Check#/ Amount Permit/ <br /> Codes Info 8 -Cash Remitted Date Sentice Re uest# Invoice# Well ID# <br /> F11D 43-08 8111/2019 6 <br /> WELL IPUMP PERMIT <br />