Laserfiche WebLink
All <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 -6232 (209) 468-3420 <br />NON-REFUNDABLE PERMIT WWW.Sjgoy.of /ehd EXPIRES 1 YEAR FROM DATE ISSUED_ <br />JOBADDRESS 5908 Jacktone Rra ClrrlZlPLinden. Cd 95236 <br />CROSS STREET Baker Rd APN 0 91 0 4C) ()1 PARCEL SIZr7 4 , 8 4 LAND USE APPLICATION # <br />OWNERNAME Ferrari Farms Inc PHONE <br />OWNERADDRESS !7071 E Baker Rd CrTY/STATE21PLinden, CA 95236 <br />CONTRACTOR Purviance Drillersr INC PHONE209-887-3554 <br />CONTRACTOR ADDRESS P.O. BOX 64 CITY/STATEIZIPL i nden CA 95236 <br />SUBCONTRACTORICONSULTANT <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />LICENSE X C-57 C-61 _: D-09 Other <br />BILLING PARTY: _. OWNER _. CONTRACTOR <br />PHONE <br />CITY/STATE/ZIP <br />NUMBER 377923 EXPIRATION <br />SUBCONTRACTORICONSULTANT <br />7/31/23 <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) '- Dibromochloropropane (4392) C Arsenic (4393) <br />INTENDED USE '/#(,Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring _ Soil Sampling/Characterization <br />Public Water System <br />If different from owner water System Name Contact Name or Phone Number <br />TYPE OF WORK New Well .. - Replacement Well Well Alteration/Modification ❑ Other <br />Monitoring Well(s) # of wells - Soil Boring(s) ilorborings Geotechnical <br />Out -Of -Service Well Out -Of -Service Well Renewal G Crass -Connection Repair <br />-: New Pump Pump Replacement Pump Repair C Raise Well Caslnn <br />9 of borings <br />AUG <br />(Drilling Method _ Mud Rotary Air Rotary - Auger Cable Tool Push Point Other `S4N fOq (� <br />Proposed Well Depth ft Excavation in diameter I Open Bottom Gravel Pack/Gravel Size E <br />ANp <br />- <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched Steel - Plastic Stainless Steel -1 Other <br />Grout Seal Depth ft _ Neat Cement (94 lb bagIS-10 gal water) Sand Cement _sack mix/7 gal water <br />Bentonite (20% solids) :J Other <br />Grout Placement Method . Pumped __ Free Fall I Other Retardant / Accelerator (name) <br />PEDESTAL Installed By = Driller Pump Contractor Other <br />Concrete Pedestal '_Dimensions: Width ft Length ft Thick in = Christy Box = Stove Pipe <br />PUMP Submersible _ Turbine - Other HP 1 ' Pump Set ft Standing Water Level �G) ft <br />I HEREBY CER IFY 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 CO ENSATI LAWS, <br />SIGNED L, � <br />TITLE � V{o �DATE `n I I G I i, <br />--�? / DEPARTMENT US ONLY <br />Application Accepted By -f--/"—Z—Li Date Area {� Employee ID#_It27�_ <br />Grout Inspection By Date C7 SPECIAL Well Permit <br />Pump Inspection By "'Y&- _ ZZ Z <br />Date WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />Cn <br />m <br />D <br />0 <br />A <br />in <br />N <br />\4F/VN� <br />� D <br />y 2021 <br />RTMEN Ty <br />NT <br />PE <br />Codes <br />SC Received Check#! <br />Info ash <br />Amount Permit/ <br />Remitted Date Servs Re Invoice# WellID# <br />U st# <br />EHD43-06 <br />fimrm,a n <br />rS* 'e 136z�3-�sTY <br />WELL (PUMP PERMIT <br />