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I WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209) 468-3420 <br />NUN-MLFUNDABLE VERMIT <br />JoB ADDRESS 7160 N Wall Rd <br />CROSS STREET Comstock RD <br />TOWNER NAME GG Orchards , Inc <br />OWNERADDRESS 26815 Shelton Rd <br />I:ALL (ZUy) Ub3-/6y7 FOR INSPECTIONS LXFIKL5 1 YEAR FROM UATE ISSUED <br />APN 09131033 <br />CONTRACTOR Purviance Drillers, Inc <br />PO Box 64 <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR n/ a <br />SUBCONTRACTOR A <br />LICENSE )g�C-57 ❑ C-61 ❑ D-09 ❑ Other <br />CITY/ZIP Linden,CA 95236 <br />SIZE 1 • 0 LAND USE APPLICATION # <br />CITYISTATE/Z1PLinden, CA 95236 <br />PHONE209-887-3554 <br />CITYISTATE/ZIP Linden, CA 95236 <br />CITY/STATE/ZIP <br />NUMBER 377923 EXPIRATION DATE 7/ 31 / 2 3 <br />DOMESTIC WELL SAMPLING: 7 General Mineral/Coliform Bacteria (4391) _ Dibromochloropropane (4392) - Arsenic (4393) <br />INTENDED USE ❑ Domestic/Private `"Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring D Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Owner. Water System Name Contact Name or Phone Number <br />TYPE OF WORK <br />❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br />❑ MonitoringWell(s) #of wells ❑ SoilBoring(s) #of borings ❑ Geotechnical <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />❑ New Pump ❑ PumD Reolacement ) f Pump Reoair r T ❑ Raise Well Casino <br />WELL CONSTRUCTION _ r ZU22 <br />Drilling Method Di Mud Rotary El Air Rotary F1 Auger (I Cable Tool El Push Point ❑ Other 'A <br />N J04Q <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Grav �A� i e <br />C Conductor Casing in diameter / Conductor Casing Depth ft RT/y;ENT <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel El Plastic ❑ Stainless Steel a Other <br />Grout Seal Depth ft ❑ Neat Cement (94 lb bag/5-90 gat water) ❑ Sand Cement sack mW7 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall D Other ❑ Retardant /Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal ❑Dimensions: Width ft Length ft Thick <br />lin ❑ Christy Box D Stove Pipe I I - <br />PUMP ❑ Submersibl(l Turbine ❑ Other HP "U Pump Set t r) i ) ft Standing Water Level I /() 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, 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 well. <br />DEPARTMENT U E)ONLY C� <br />Application Accepted B Date ZZ Area ! 7 / Employee ID <br />Grout Inspection By Date 0 S ECIAL Well Permit <br />Pump Inspection By "t /L,4 Date �� ❑ WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />T <br />M <br />D <br />0 <br />M <br />rn <br />PE SC Received <br />Codes Info 5V <br />Check#! <br />Cash <br />Amount Permit/ <br />emitted Date Service Re uest # Invoice # well ID# <br />Z �1Sp <br />22 O S <br />747.1 <br />Ei�JG4i-GG i0.+!2G2I Pace I ort \Veil /Pump Pcrmit <br />1��9�� 75 <br />