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I WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />IVUIV-KFFUNDABLE t'ERMIT L.ALL (LUy U04 -t b:1 r FOR INSPEG I IUNS CAr1KC0 "1 T EAK FRUM UA I E ISSUEU <br />JOBADDRESS 16940 E Davis Rd CrrYtziP Linden,CA 95236 <br />CROSS STREET ArC herda l e RD APN 091 14009 PARCEL SIZErl n�LAND USE APPLICATION # <br />OWNER NAME Ferrari Brothers Properties,LLC PHONE <br />OWNER ADDRESS 5960ArrhPrr�alRd CITY/STATEIZIP Linden, -CA 95236 <br />1 <br />CONTRACTOR Purviance Drillers PHONE 209 887-3554 <br />CONTRACTOR ADDRESS P-0. BOX 64 CITY/STATE/ZIP Linden , CA 95236 <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE x-xC-57 ❑ C-61 ❑ D-09 ❑ Other <br />CITY/STATEIZIP <br />NUMBER 3 7 7 9 2 EXPIRATION DATE 7/ 31 / 2 3 <br />DoMEsTlc WELL SAMPLING: F General Mineral/Coliform Bacteria (4391) -- Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE ❑ Domestic/Private Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/�,tfaractenzation <br />El Public Water System / VA <br />If different from Owner. Water System Name Contact Name or Pho <br />TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings ❑ GeotechnicadA Al ' - # of bori <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection gAgsir <br />l/L1 <br />New Pump ❑ Pump Replacement Pump Repair ❑ Raise Well Casing PA„0.4n, <br />WELL GONSTRUCTION "C q % •,` UN/�. ` vU <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other N �EpgRT�q NTy <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size T in <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel u Other <br />Grout Seal Depth ft ❑ Neat Cement (94 lb bagl5-10 gal water) ❑ Sand Cement sack mixl7 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant /Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal ❑Dimensions: Width ft Length ft Thick <br />in ❑ Christy Box ❑ Stove Pipe <br />PUMP Submersible❑ Turbine ❑ Other HP C Pump Set r I 0 ft Standing Water Level 1S56 ft <br />Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the following items: GPS <br />Coordinates, property lines, adjoining properties, water bodies or courses, drainage pattern, roads, existing wells, structures, <br />potential sources of contamination, sewers or private disposal systems. Include distance from two property lines. For Domestic, <br />Agriculture, Industrial well, provide location of any water wells or surface water within 204' radius of proposed well. <br />DEPARTMENT USE ONLY <br />Application Accepted By <br />Grout Inspection By _ <br />Pump Inspection By J '"` <br />Soil Boring Inspection By <br />COMMENTS t r•S1`c 03r . c;e + (-)f'S <br />p Yd <br />Date f 1 v'• ' Area Em to ee ID# -1^ <br />Date ❑ SPECIAL Well Permit <br />Date S Z ❑ WAIVER Received <br />T <br />m <br />D <br />v <br />v <br />m <br />m <br />CA <br />rn <br />PE SC Received Check#/ Amount Date <br />Codes Info B Cash Remitted <br />Permit! Invoice # <br />Service Request # <br />Well ID# <br />:,� :: �� % SGS--. � 1 S u? • (2 • Z <br />(7 2 <br />E}iD043.O6 10!?512021 o�' 7�7sz� Well /Pump Permit <br />