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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1886 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)4683420 <br /> NON-REFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> CShl <br /> z in Rd 4Ci'_co�a.l./<�(� ( N <br /> JOB ADDRESS Av7Y+d�1 �r � CIIY/ZIP L✓)�1 e ri m <br /> ld ryh &�. _ YY D <br /> CROSS STREET o- q-: OARCEL SIZE <br /> LAND USE APPLICATION# o <br /> z <br /> OWNER NAME GG Orchards,INC PHONE209 470 2931 y <br /> OWNER ADDRESS 26815 Shelton Rd CrTYlSTATvzIPLinden,CA 95236 <br /> CONTRACTOR Purviance Drillers, INC PHONE209-887-3554 <br /> CONTRACTOR ADDRESS P-O- BOX 64 CrrY/STATEMPL i nd en CA 95236 <br /> SUBCONTRACTORICONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZJP <br /> LICENSE XC-57 C-61 _)D-09 _Other NUMBER 377923 EXPIRATIONDATE 7/31/21 <br /> BIWNG PARTY: _:OWNER ^CONTRACTOR ;; SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:L General Mineral/Coliform Bacteria(4391)�]Dibromochloropropane(4392)C Arsenic(4393) <br /> INTENDED USE Domestic/Private )Lr IrrigatioNAgricultural Industrial _Water Quality Monitoring L'Soil Sampling/Characterization <br /> Public Water System <br /> If dllferent from Owner. Water System Name Contact Name or Phone Number c <br /> TYPE OF WORK 7 New Well F Replacement Well :Well Alteration/ModificationOther /k M` <br /> Monitoring Well(s) #of wells Soil Boring(s) #orb0"n� 7-1 Geotechnical xofborings l•r VAO <br /> Out-Of-Service Well �Out-Of-Service Well Renewal Ll Cross-Connection Repair Sr <br /> New Pump 7 Pump Replacement Pump Repair C.Raise Well Casing <br /> WELL CONSTRUCTION' �^A,JO D 2020 Drilling Method Mud Rotary Air Rotary [,Auger ri Cable Tool Li Push Point Other ^t I V1. v/N <br /> co <br /> Proposed Well Depth ft Excavation in diameter ;l O m ❑ <br /> Open Bottom Gravel Pack/Gravel Size <br /> Conductor Casing in diameter I Conductor Casing Depth_ft A. <br /> pq T 7-y <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched ❑Steel C Plastic '1 Stainless Steel .I Other ANT <br /> Grout Seal Depth ft ;Neat Cement(94 Ib bag/5-10 gal water) C Sand Cement sack mixl7 gal water <br /> G Bentonite(20%solids) J Other <br /> Grout Placement Method Pumped 7 Free Fall fi Other _Retardant/Accelerator(name) <br /> PEDESTAL Installed By -Driller L'Pump Contractor ❑ Other <br /> Concrete Pedestal Dimensions:Width It Length ft Thick in ::Christy Box C Stove Pipe <br /> PUMP : Submersibl Turbine .1 Other HP 500 PUMP Set-0f)—ft Standing Water Levell l5 R <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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> I IY i-- -°'/'{�rL7iR ADVANCE NOTICE REQUIRED FOR INSPE TIONt�S-PI-FAS!!CALL ir309)95?--rcq- <br /> SIGNED \. Jl.I�-- � TRLE �/}L-�1/in DATE `/. ��.0 GJ <br /> a <br /> F <br /> DEPARTMENT USE ONLY <br /> e r� <br /> Application Accepted By '������ Date 3 Dad Area � `/�7 Employee ID# F <br /> Grout Inspection By Date D SPECIAL Well Permit <br /> Pump Inspection By .(ion t 1 l✓ 1 Ly xt 4 Date 7."1> ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth tt <br /> COMMENTS <br /> PE Sc Received Check#/ Amount Permit/ <br /> Codes Info sh Remitted Date Service Re ue # Invoice# Well ID# <br /> r <br /> - EHD 4306 6111!!979 WELL(PUMP PERMIT <br />