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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 />rvv,v-RCrUINUAtsLt rtNMl l GALL (ZUU)y53-!tiy( FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 15988 E Eight Mile Rd c,TY/z,PLinden, CA 95236 <br />CROSS STREET Tully Rd APN 0 910 8 0 2 9 PARCEL SIZE 3 . 0 5 LAND USE APPLICATION #F <br />OWNER NAME Solari Ranch Produce PHONE <br />OWNER ADDRESS PO Box 477 CITY/STATE/Zip Linden, CA 95236 <br />CONTRACTOR Purviance Drillers, Inc PHONE209-887-3554 <br />PO Box 64 Linden, CA 95236 <br />CONTRACTOR ADDRESS CITY/STATE/ZIP <br />SUBCONTRACTOR n/ a <br />ADDRESS <br />LICENSE ) j 57 ❑ C-61 ❑ D-09 C Other <br />CITYISTATEIZIP <br />NUMBER 3 7 7 9 2 3 EXPIRATION DATE 7/ 31 / 2 3 <br />DOMESTIC WELL SAMPLING: = General Mineral/Coliform Bacteria (4391) __ Dibromochloropropane (4392) - Arsenic (4393) <br />INTENDED USEomestic/Private ❑ Irrigation/Agricultural ❑ Industrial D Water Quality Monitoring C Soil S amp iing/Ch aracterization <br />r3public Water System <br />If different from Owner. Water System Name Contact Name or Phone Number <br />IYPE OF WORK <br />C New Well D Replacement Well C Well Alteration/Modification ❑ Other <br />D Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings ❑ Geotechnical —j-. rV 1 <br />❑ Out -Of -Service Well ❑. Out -Of -Service Well Renewal ❑ Cross -Connection Repair RE! <br />�. <br />D New Pum -7 Pump Replacement Pump Re air ❑ Raise Well CasingEI V ED <br />WELL CONSTRUCTION V (� O 222 <br />Drilling Method Mud Rotary a Air Rotary t7 Auger Cable Tool F-7Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Grav AQUKUN —Aeter <br />Conductor Casing in diameter I Conductor Casing Depth ft HEALTH��N L <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched D Steel ❑ Plastic L Stainless Steel � OthherPARTMENT <br />Grout Seal Depth ft -E Neat Cement (94 Ib bag/5-10 gal water) C Sand Cement sack mix17 gal water <br />Bentonite (20% solids) C Other <br />Grout Placement Method D Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By D Driller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal ❑Dimensions: Width ft Length ft Thick <br />�in ❑ Christy Box ❑ Stove Pipe <br />Pump ubmersible ;Turbine 7- Other HP � Pump Set yrz °.<• ft Standing Water Level � ft <br />Plot Plan Requirements: Attach.a plot plan with the exact location of water well with respect to the folloltving 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 ♦•ell. <br />:iii Elti.'. . _ .. e_ ( ..... <br />DEPARTMENT USE PNLY <br />Application Accepted By - fir _ - Date � (f'Z Z Area t Employee ID S <br />Grout Inspection ByDate G SPECIAL Well Permit <br />Pump Inspection By Date ❑ WAIVER Received <br />Soil Boring Inspection By _ x Date Constructed Well Depth ft <br />COMMENTS �1'� ' 14 0_� <br />m <br />D <br />0 <br />m <br />PE Sc Received <br />Codes Info B <br />Check#/ Amount Permit/ <br />Cash Remitted Date Service Re uest# Invoice # Well ID# <br />' n c-5-( <br />5�--: 22 P nn <br />i <br />I <br />EH0043-05 10.'25;2021 page I cf 2 <br />will i Pump P—if <br />