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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />�wn-crUIVUROL-r- Ptt(MI I k;ALL <br />JOBADDRESS 3880 Alpine RD <br />ICROSSSTREET Fairchild Rd <br />1OWNERNAME Prieto Farms <br />953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />CrryZPStockton,CA 95215 <br />APN 08908004 PARCEL SIZE2 0- 9 4 LAND USE APPLICATION # <br />OWNERADDRESs 249 Roval Oaks Ct <br />CONTRACTOR Purviance Drillers, Inc <br />PO Box 64 <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR nI a <br />SUBCONTRACTOR ADDRESS <br />LICENSE XlyC-57 ❑ C-61 ❑ M9 ❑ Other <br />PHONE <br />CITY/STATE/ZIP Lodi , CA 95240 <br />PHONE209-887-3554 <br />Crry/STATEMP Linden, CA 95236 <br />CITY/STATE/ZIP <br />PHONE <br />EXPIRATION DATE <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) E Dibromochloropropene (4392) D Arsenic (4393) <br />INTENDED USE ❑ DomesticJPrivateIrrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br />❑ Public Water Syst m <br />If different from Owner Water System Name Contact Name or Phone Number <br />TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewa <br />` ,New Pump 0 Pump Replacement ❑ Pumo Reoair <br />❑ Other <br />#of borings ❑ Geotechnical <br />1 ❑ Cross -Connection Repair <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel <br />❑ Conductor Casing in diameter 1 Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel <br />Grout Seal Depth ft ❑ Neat Cement (94 /b bag/5-10 gal water) ❑ Sand Cement <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 />m <br />m <br />n <br />0 <br />0 <br />m <br />W <br />N <br />Sq N'jo'A -mac <br />❑ Other Pp RTQ I <br />� <br />_ sack mix/7 gal water <br />LU P RSubmersible❑ Turbine ❑ Other HP �%� Pump Set D ft Standing Water Level _11&,_ ` 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, adjoihing 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 welt. <br />DEPARTMENT USE ONLY <br />Application Accepted By: Date �1 $�a�/a� Area 1 49 EmployeeID# F <br />Grout Inspection By Date ❑ SPECIAL Well Permit <br />Pump Inspection By X Date )- 0 WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS_ NeVj p 4_11 Pery►7rf yJP00 yd386. olu rcl) cifes 6 "'C II <br />1 41-C . � �''t- Z i. I q c5 1. <br />PE <br />Codes <br />SC ' Received <br />Info <br />Check#/ <br />Cash <br />Amount permit/ <br />Remitted Date Service Re uest # Invoice # Well ID# <br />380 <br />0s <br />page 1 of 2 Well / Pumo Permit <br />- - !11671 `��-7 /y 1071L;61, <br />