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1 WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />Sr V1Y-r[trUNLJAtSLt rtKMI I t,ALL (LUU) y5s-(bU/ FOR INSPECTIONS LAVIKtS 'I YEAR FROM DATE ISSUED <br />JOB ADDRESS 1-9617 R Harney Ln cITY/zIP Lcdi,CA 95240 <br />CROSS STREET T 171 1 v RF) APN 9 (),)r 9 PARCEL SIZE 1 - 03 LAND USE APPLICATION # <br />OWNER NAME r lants and Produce PHONE <br />OWNER ADDRESS _ 15777 E Harney Ln CITylSTAT=P Lodi , CA 95240 <br />CONTRACTOR Purviance Drillers INC PHONE209 887 3554 <br />CONTRACTOR ADDRESS P.O. BOX 64 C1TYlSTATE/ZIPj,lnder, ., C 5 9r;236 <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />CITY/STATE/ZIP <br />PHONE <br />LICENSE ki C-57 f; C-61 11 D-09 F Other NUMBER 3 7 7 9 2 3 EXPIRATION DATE 7 13 1 i 2-3 <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE Domestic/Private 171 Irrigation/Agricultural I I Industrial -1. Water Quality Monitoring P Soil Sampling/Characterization <br />Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />Ln <br />I <br />D <br />a <br />0 <br />M <br />m <br />N <br />TYPE OF WORK <br />P New Well 1-1 Replacement Well I Well Alteration/Modification f1 Other <br />N <br />A. W� <br />Flip <br />r' Monitoring Well(s) # of wells P Soil Boring(s) #orbor ngs 11 Geotechnical <br />of <br />11 Out -Of -Service Well I I Out -Of -Service Well Renewal n Cross -Connection Repair <br />P New Pum *Pump Replacement ii Pump Repair I! Raise Well Casing <br />Amy <br />WELL CONSTRUCTION I <br />Drilling Method <br />Ii Mud Rotary P Air Rotary 1-1 Auger r1 Cable Tool I, Push Point P Other sqN J <br />Proposed Well <br />Depth ft Excavation in diameter I1 Open Bottom � 11 Gravel Pack/Gravel <br />Si* <br />it Conductor Casing in diameter / Conductor Casing Depth ft <br />DE 61V 7-, U <br />pQRT <br />Y <br />Well Casing <br />Diameter _ in Thickness/Gauge/ASTM Sched P Steel P Plastic 11 Stainless Steel <br />I I Other <br />Grout Seal <br />Depth ft n, Neat Cement (94 lb bag/5-10 gal water) P Sand Cement <br />sack mW7 gal water <br />i i Bentonite (20% solids) I1 Other <br />Grout Placement Method 11 Pumped P Free Fall 1 Other P Retardant / Accelerator (name) <br />PEDESTAL Installed By il Driller P Pump Contractor Other <br />Concrete Pedestal C1 Dimensions: Width ft Length ft Thick <br />in P Christy Box I I Stove Pipe <br />PUMPSubmersiblen Turbine P Other HP 1 __ Pump Set _ ft Standing Water Level ft <br />Plot Plan Req irements: 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 200' radius of proposed well. <br />DEPARTMENT USE <br />%%ONLY <br />Application Accepted By Date S/a y/ �a Area yh Employee (D# T'wn k 1 <br />Grout Inspection By 4 4 Date ❑ SPECIAL Well Permit <br />Pump Inspection By 1 Date - l `' �- ❑ WAIVER Received <br />Soil Boring Inspection By Date Constructgd Well Depth ft <br />COMMENTS Docu coo r I vl afrs 6 v4C I) :7. 1 ✓ 5 25 '- L. L ` <br />PE Sc Received Check#/ Amount <br />Codes Info B Cash Remitted <br />Date Permit/ Invoice # Well 1D# <br />S rvice R t# <br />LIM os'o � <br />A. W� <br />Flip <br />EHD043-0604;07,2022 6 n -/- <br />- /�*7/z�2— Page Iot2 Well; PumpPernr¢ <br />