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} WI=LL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 466-3420 <br />NUN-KEFUNDABLE t'ERMIT GALL (ZU9) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOBADDRESS 5841 E St Rt Hwy 26 clTy/zfp Stockton, CA 9521 5 <br />CROSS STREET Avalon Dr APN 1.0123020 PARCEL SaE1 5 - 8 3 LAND USE APPLICATION <br />OWNER NAME D11e0 Farms PHONE <br />OWNERADDRESS 2037 W Bullard Ave #148 <br />CONTRACTOR Purviance Drillers, Inc <br />PO Box 64 <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR, n / O <br />SUSCONTRACTOR ADDRESS <br />LICENSE XXC-57 C C-61 D D-09 =, Other <br />CITY/STATEIZIP Fresno,CA 93711 <br />PHONE209-887-3554 <br />CITYISTATEIZIP Linden, CA 95236 <br />PHONE <br />CITY/STATEIZIP <br />NUMBER 3 7 7 9 2 3 EXPIRATION DATE 7/31/23 <br />DOMESTIC WELL SAMPLING: = General Mineral/Coliform Bacteria (4391) - Dibromochloropropane (4392) - Arsenic (4393) <br />INTENDED USE C Domestic/Private "ligation/Agricultural D Industrial ^ Water Quality Monitoring D Soil Sampling/Characterization <br />- Public Water System <br />It different from Ormer: Water System Name Contact Name or Phone Number 6 Al <br />TYPE OF WORK C New Well D Replacement Well C Well Alteration/Modification O Other <br />C Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings ❑ Geotechnical # of boring'�Q <br />C Out -Of -Service Well = Out -Of -Service Well Renewal ❑ Cross -Connection Repair UC7 <br />yl�� <br />New Pumc D Pump Replacement C Pump Repair _ D Raise Well Casing N� <br />WELL CONSTRUCTION�q �( lR�C1,2� <br />t 7, FNM (�l� CO <br />Drilling Method - Mud Rotary Air Rotay D Auger C Cable Tool D Push Point D Other__ D E .V <br />Proposed Well Depth #t Excavation in diameter G Open Bottom ❑ Gravel Pack/Gravel Size h/�j meter <br />G Conductor Casing in diameter / Conductor Casing Depth Y•, i <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched --1SteelC Plastic L Stainless Steel �j Other <br />Grout Seal Depth ft - Neat Cement (94 lb bag/5-10 gal wafter) n Sand Cement sack mW7 gal water <br />Bentonite (20% solids) a Other _ <br />Grout Placement Method DC Pumped ❑ Free Fail D Other 0 Retardant / Accelerator (name) <br />PEDESTAL Installed By 0 Driller u Pump Contractor C Other <br />D Concrete Pedestal , ,Dimensions: Width ft Length ftThick <br />lin - Christy Box ❑ Stove Pipe <br />PUMP _ Submersible'$Turbine ❑ Other HP - "-�j Pump Set kt (. ft Standing Water Level L % ft <br />Plot Plan Requirements: Attach.a plot plan with the exact location of water well with respect to the following items: CPS <br />Coordinates, property lines; adjoining properties, water bodies or courses, drainage pattern, roads, existing welts, 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 />IjEPJkRTMENT U ONLY <br />Application Accepted By Date Area Employee ID#� <br />Grout Inspection By Date 0 SPECIAL Well Permit <br />Pump inspection By , Date i Z- f_i WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS 'ti , uT 1-11- L - kZ (' r Zc 11, <br />PEC <br />Received Check#/ Amount Date Permit/ Invoice # Well ID# <br />o es Info By Cash Remitted Service Re uest# <br />/0- 1' i I� <br />I <br />EHD043-06 IG= 2021 Pa- 1 ort \t6; PumoPenna <br />T <br />�m <br />m <br />D <br />0 <br />c <br />�v <br />