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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />- r_r_U1YVAGLC r-r-KIY111 WWW <br />JOB ADDRESS 16940 E Davis <br />CROSSSTREET Archerdale RD APN 09114009 <br />OWNER NAME Ferrari Bros Properties, LLC <br />OWNER ADDRESS 5960 Archerdale Rd <br />CONTRACTOR Purviance Drillers, INC <br />CONTRACTOR ADDRESS P - 0 - BOX 64 <br />SUBCONTRACTOR/CONSULTANT <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />LICENSE X C-57 C-61 D-09 <br />BILLING PARTY: OWNER <br />a EXPIRES 1 YEAR FROM DATE ISSUED <br />CITY/ZIP Linden, CA 95236 <br />PARCEL SIZE �Zb LAND USE APPLICATION # <br />PHONE209-607-3744 <br />CITY/STATE/ZIP Linden, CA 95236 <br />PHONE209-887-3554 <br />CITY/STATE/ZIPL i n d e n CA 95236 <br />PHONE <br />CITY/STATE/ZIP <br />Other NUMBER 377923 EXPIRATION DATE 7/ 31 / 21 <br />CONTRACTOR SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: E General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) i Arsenic (4393) <br />INTENDED USE ,11 Domestic/Private ,Irrigation/Agricultural Industrial �] Water Quality Monitoring Soil Sampling/Characterization <br />A Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />rrt yr VVVKA New vveu fi Keplacement Well Well Alteration/Modification I Other <br />Monitoring Well(s) # of wells Soil Boring(s) # of borings Geotechnical # of borings <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />New Pump - Pump Replacement Pump Repair Raise Well Casino <br />Drilling Method X Mud Rotary - Air Rotary Auger Cable Tool Push Point Other <br />Proposed Well Depth ft Excavation 3 in diameter 9 Open Bottom - Gravel Pack/Gravel Size n diameter <br />Conductor'Casing f* in diameter / Conductor Casing Depth ft <br />C; Well Casing Diameter � Sqrn Thickness/Gauge/ASTM Sched .13F )i Steel Plastic Stainless Steel i Other <br />Grout Seal Depth CO - t ft Neat Cement (94 /b bag/5-10 gal water) }{ Sand Cement -W. _6 sack mix/7 gal water <br />Bentonite (20% solids) J Other <br />Grout Placement Method X Pumped Free Fall I Other Retardant / Accelerator (name) <br />PEDESTAL Installed By _ Driller _ Pump Contractor I-.. Other <br />Concrete Pedestal Dimensions: Width ft Length ft Thick in Christy Box Stove Pipe <br />Pump Submersible Turbine Other HP Pump Set ft Standing Water Level ft <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />`ICE NOTICE REQUIs: " _. PICC'. _. -- 'till <br />SIGNED TITLE Corporate Secretary DATE6 /1 8/21 <br />EP.ARTMENT USE ONLY <br />Application Accepted By U u Date <br />Grout Inspection By '^"ALu Date (Z G Z <br />Pump Inspection By Date <br />Soil Boring Inction By Date <br />COMMENTS r5% -� ji t ',e ; I I c ✓1 ti<`vZ,t ('..r'\A e n X <br />LI v� l'1 <br />Area j Employee ID# <br />_i SPECIAL Well Permit <br />Ll WAIVER Received <br />_ft <br />T <br />M <br />D <br />0 <br />0 <br />M <br />M <br />cn <br />CE 1"'., <br />PE <br />Codas, <br />SC Received Check#/ Amount Date <br />Info 13y VPz -Cash Remitted <br />Permit/ <br />Service Re uest # Invoice # Well ID# <br />70 SIC2 2 i ( , <br />Li <br />31 <br />C— yW l _ V7 rL.SKC�'` L17 � v �, i wY 5 �C�t�[C�'V`'�1 •"1 �' r '44 1A J':;,. WELL /PUMP PERMIT <br />