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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 46"420 <br />14UN-KEFUNDABLE PERMIT www.si-gov.org/ehd EXPIRES t YEAR FROM DATE ISSUED <br />JosADORESS14353 N. Clements CITY/ZIP Lodi 95240 <br />APNQ 5 11 S 01 1—' PARCEL SIZE?(1 1 <br />CROSS STREET Kettleman LAND USE APPLICATIOjjN# <br />OWNER NAMEPrletO Farms- /�� PHONE <br />OWNERADDRESS 2328 Brittanv Ln CITY/STATE/ZIP Lodi ,Ca 95242 <br />CONTRACTOR Purviance Drillers, INC PHONE209-887-3554 <br />CONTRACTOR ADDRESS P - O - BOX 64 CITY/SrATEZPLinden CA 95236 <br />SUBCONTRACTORICONSULTANT <br />SUBCONTRACTORICONSULTANT ADDRESS <br />LICENSE x C-57 C-61 <br />BILLING PARTY: _. OWNER <br />D-09 <br />CITYISTATE21P <br />Other NUMBER 377923 <br />='.CONTRACTOR SUBCONTRACTOR/CONSULTANT <br />PHONE <br />EXPIRATION DATE 7/ 3 1/ 2 1 <br />DOMESTIC WELL SAMPLING: F General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) E Arsenic (4393) <br />INTENDED USE Domestic/Private V Inigation/Agricultural " Industrial - Water Quality Monitoring E Soil Sampling/Characterization <br />Public Water System <br />If different from 0—n Water System Name contact Name or Phone Number <br />rre yr vvUKn .. New vveii Keplacement Well C Well AReration/lvtodification ; : Other <br />Monitoring Well(s) # of wells E Soil Boring(s) # of borings _1 Geotechnical ft of borings <br />_ <br />Cut -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />VNew Pump E Pump Replacement :; Pump Repair Raise Well Casino <br />Drilling Method - Mud Rotary C Air Rotary i Auger :: Cable Tool C Push Point Other <br />Proposed Well Depth ft Excavation in diameter ;1 Open Bottom P Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Schad i Steel _ Plastic Stainless Steel E Other <br />Grout Seal Depth ft Neat Cement (941b bagl5-10 gat water) Sand Cement sack mixP gal water <br />Bentonite (20% solids) D Other <br />Grout Placement Method .. Pumped :: Free Fall - Other Retardant / Accelerator (name) <br />PEDESTAL Installed By :1 Driller :� Pump Contractor E Other <br />_ Concrete Pedestal is Dimensions: Width ft Length ft Thick in L: Christy Box C Stove Pipe <br />(Pump Submersible&Turbine ^Other HP Pump Set it Standing Water Level ao it <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 />H <br />M <br />D <br />0 <br />A <br />N <br />DEPARTMENT USE ONLY <br />y/ , <br />Application Accepted By _ _ 4/� � Date G �?✓ Area `t i (' Employee ID# <br />Grout Inspection By A I A Date SPECIAL Well Permit <br />Pump Inspection By I Date Z Z ❑ WAIVER RQC81Ved <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTSV�� I E ,' K )'} �^I IDD 71 :7] <br />WELL /PUMP PERMIT <br />WENT <br />oEIVED <br />2 1 2020 <br />UIN COUNTY <br />INMENTAL <br />EPARTMENT <br />