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V WELLIPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCK TION CA 95205 - (209) 468-3420 <br />1vviv-r:CrUN1JAt3Lt rl=RMIT t:ALL LUy) y5S-!bUt FOR INSPECTIONS tXF'lKtS 'I YEAR FROM LIATE ISSUED <br />Joe ADDRESS Archerdale Rd cITY/zIP Linden,CA 95236 <br />CROSS STREET Oak Ave APN 09113.066 PARCEL SIZE 7 - 0 7 LAND USE APPLICATION # <br />OWNERNAME Ferrari Farms Inc /%1feyle 3 vie-,' 'Yll° FP.r<<{f1 PHONE <br />OWNER ADDRESS 17071 E Baker Rd CITY/STATEIZIP 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 />SUBCONTRACTOR A <br />LICENSE IX --57 C C-61 ❑ D-09 ❑ Other <br />CITYISTATE/ZIP <br />77923 EXPIRATIONDATE 7/31 /23 <br />DOMESTIC WELLSAMPUNG: - General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) = Arsenic (4393) <br />INTENDED USE ❑ Domestic/PrivateIrrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring D Soil Sampling/Characterization <br />0' Public Water Syst m <br />If different from Owner. Water System Name Contact Name or Phone Number <br />TYPE OF WORK C New Well D Replacement Well C Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) of borings ❑ Geotechnical of borings <br />❑ Out -Of -Service Well L Out -Of -Service Well Renewal ❑ Cross-Conneclion Repair <br />C New Pumo ❑ Pumo Replacement -aPumo Repair ❑ Raise Well Casino <br />Drilling Method - Mud Rotary ❑ Air Rotary ❑ Auger C Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter a Open Bottom ❑ Gravel Pack/Gravel Size in diamete <br />Conductor Casing in diameter / Conductor Casing Depth ft � �A C�- <br />Well CasingDiameter in Thickness/Gauge/ASTM Sched n Steel 0 Plastic ❑ Stainless Ste C1MI <br />Grout Seal Depth ft D Neat Cement (94 Ib bag/5-10 gal water) ❑ Sand Cement R F ('_ E # 9 gal wate <br />Bentonite (20% solids) D Other <br />Grout Placement Method D Pumped D Free Fall ❑ Other ❑ Retardant / Accelerator (name)_____.e_I_ir n nnne__ <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal ❑Dimensions: Width ft Length ft Thick SAN JOAQUIN COUNTY <br />in ED Christy Box ❑ Stove Pipe ENVIRONMENTAL <br />PUMP ❑ Submersible�Turbine ❑Other HP �'� :1 Pump Set _ ft Standing Water Level ft <br />Plot Plan Requirements:t ch,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 wafer within 200' radius of proposed well. <br />DEPARTMENT USE ONLY <br />Application Accepted By L L Date 3 07� Area I Employee ID -1 r r Iew h C <br />Grout Inspection By 4 Date 10 SPECIAL Well Permit <br />Pump Inspection By Date z D WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS '� , p� j (-L l <br />m <br />D <br />0 <br />c <br />m <br />m <br />to <br />PE <br />Codes <br />SC Received Check#/ <br />Info S Cash <br />Amount Dae Permit! Invoice # Well 1D# <br />Remitted I Service Re quest# <br />Sed <br />o so rc <br />7 <br />I I ! I f <br />I <br />I <br />viDO:3-C.i I0:75,202I Pz.e I oft 11'el!/Pump PCMm <br />1`47002-0 <br />