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- , E-MAILED,, <br /> 1 WELL/PUMP PERMIT 3-a4 ) <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON A 520 - (209 468 3420 <br /> NON-REFUNDABLE PERMIT CALL 209)953-7697 FOR INSPECTIONS EXPIRES l YEAR <br /> 95236 <br /> DATE ISSUED LP <br /> ig�3: _ i e Linden, A m <br /> CITY/ZIP <br /> JOB ADDRESS D <br /> Tully APN 09108029 PARCEL SIZE 3 -0 5 LAND USE APPLICATION# z <br /> CROSS STREET m <br /> N <br /> OWNER NAME Solari Ranch Produce _ PHONE fn <br /> PO Box 477 CITYISTATEIZIP Linden, CA 95236 <br /> OWNER ADDRESS 2 0 9_8 8']-3 5 5 4 <br /> Purviance Drillers, Inc PHONE <br /> CONTRACTOR Linden, CA 95236 <br /> PO Box 64 CITYISTATE/ZIP <br /> CONTRACTOR ADDRESS <br /> SUBCONTRACTOR <br /> n/a PHONE <br /> CITYISTATEIZIP <br /> SUBCONTRACTOR ADDRESS NUMBER 377923 EXPIRATION DATE 7/31 /2 0 2 5 <br /> LICENSE ><—� 57 11 C-61 [] D-09 CI Other <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE >I)omestic/Private n Irrigation[Agricultural U Industrial Ll Water Quality Monitoring a Soil Sampling/Characterization <br /> 11 Public Water System Contact Name or Phone Number <br /> K different from Owner: Water System Name <br /> TYPE OF WORK t 1 New Well [1 Replacement Well U. Well Alteration/Modification [I Other <br /> m of borings ❑ Geotechnical � n N <br /> I 1 Monitoring Well(s) #of wells r7 Soil Boring(s) <br /> L1 Out-OfService Well [1 Out-Of-Service Well Renewal ❑ Cross-Connection Repair VICo <br /> '><New_Pump I 1 Pump Replacement (I Pump Repair a Raise Well Casing <br /> WELL CONSTRUCTION SAIV U0 ��ZS <br /> Drilling Method I1 Mud Rotary [I Air Rotary [] Auger D Cable To U Push Point [1 Other <br /> Proposed Well Depth _ft Excavation in diameter U Open Bottom [1 Graavel Pack/Gra SiiF� R �/O�J e er <br /> 11 Conductor Casing in diameter I Conductor Casing Depth ENT <br /> [; Steel t l Plastic I Stainless Steel [1 Other_ <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched [I Sand Cement sack mixl7 gal water <br /> Grout Seat Depth ft Ll Neat Cement(94 Ib bag/5-io gal water) <br /> [1 Bentonite(20%solids) [I Other <br /> t l Retardant!Accelerator(name) <br /> Grout Placement Method [l Pumped 11 Free Fail [1 Other <br /> ri, <br /> EDESTAL Installed By L' Driller [] Pump Contractor [1 Other <br /> I Concrete Pedestal I]Dimensions:Width ft Length ft Thick / <br /> I I Christy Box II Stove Pipe <br /> PUMP <br /> ubmerslble Turbine 11 Other HP Pump Set ft Standing Water Level ft <br /> Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the tolloning items <br /> Coordinates, property lines, adjoining properties, Water bodies or courses, drainage pattern, roads, existing wells, structures, <br /> ate disposal systems. Include distance from two property lines.For Domestic, <br /> potential sources of contamination, sewers or priv <br /> Agriculture,Industrial well,provide location of any water wells or surface water within 200' radius of proposed well. <br /> 'ii:\;\II' I?�I-?Gi'I:-'.I%�:L1 C' :\OTIC'I;:RFQ�i[IRrD FOR LNSnLC'TIO\S-i I_I:ASE C'Al.I.(209)953-7697 <br /> ,/ DEPARTMENT USE ONLY <br /> Application Accepted By <br /> /I145& Date 3 ��� Area_ Employee ID#_�_ <br /> Grout Inspection By <br /> Date 1 SPECIAL Well Permit <br /> l WAIVER ReG@IVed <br /> �� <br /> Pump Inspection By Date <br /> Soil Boring Inspection By <br /> � Date Constructed Well Depth ft <br /> COMMENTS 140M S <br /> pE SC Received Check#/ Amount Permit! Invoice# Well ID# <br /> Codes Info B ash Remitted <br /> Date Service Re uest# <br /> 3 p Q `6r -- 17Z-0 2k ' 5 13 <br /> abbd <br /> / �j Q� L�7� Well,Pwnp perm <br />