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WELL / rU1Vlr rL' WV111 % SAN JOAQVIN COUNTY ENVIRONMENTALHEALTH D' 'TMENT 304E WEBER, It"'FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT *awoALL 209 953-7697 FOR INSPECTIONS ,FIRES 1 YEAR FROM/DATE ISSUED JOB ADDRESS 4343 McKinley Ave CITU/ZIP Stockton qob y 0 CROSS STREET 1ri nn APN PARCEL SIZE A H OWNERNAME Sierra Organics PHONE OWNERADDRESS P. O• BOX 31750 CITY/STATE/ZIP Stockton, CA 95213 CONTRACTOR Purviance Drillers INc. PHONE 209-887-3554 �( CONTRACTORADDRESS P•O•BOX 64 CITY/STATE/"LIP Linden Ca 95236 SUBCONTRACTOR n/a PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE RI C-57 ❑C-61 ❑D-09 ❑Other NUMBER 177-9-2-3— EXPIRATION DATE 8/21 /0 2 GEOGRAPHICALINFORMATION: Coordinates X V Township _ Range_ Section INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Chamnterizetion ❑Public Water System ) IrdiOnamfirom Owner: water system Nam Contact Nam or Phone,Number TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other ❑Monitoring Well(s) numberofwells ❑Soil Borings) oumberofborings 11 Geotechnical numberoftaring, NI Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑New Pump ❑Pump Replacement ❑Pump Repair ❑Cross-Connection Repair WELL CONSTRUCTION Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other Proposed Well Depth It Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter ❑Conductor Casing in diameter / Conductor Casing Depth It Well Casing Diameter _ in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other Grout Seal Depth It ❑Neat Cement(94/h hug/5-10 gal water) ❑Sand Cement .rack nox/7 gal water ❑Bentonite(200/a solids) ❑Manufacturer Spec%solids_% Name ❑Specs on File ❑Specs Submitted Grout Placement Method ❑Pumped ❑Free Fall 13 Other ❑Retardant/Accelerator(name) PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other ❑Concrete Pedestal Dimensions: Width_ R Length R Thick in ❑Christy Box ❑Stove Pipe PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set It Standing Water Level It WELL DESTRUCTION IROpen Bottom ❑Gravel Pack ❑Uncased r ❑Other Well Diameter, 10 Total Depth 1 31 B Depth to Water �J g 0 ❑Casing to be Perforated from It to R Sealing Material ❑Neat Cement(94 Ib hag/5-10 gal valer) NSand Cement 10 _5 sack mix/7 gal water ❑Bemonite Pellets ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Placement Method IRPumped ❑Free Fall ❑Other ❑Complete with Mushroom Cap ft below grade ❑Complete to Existing Surface Pad I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. I MUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS SIGNe �liLticir-e►i/ TITLE Corporate Sc rrc-tare DATE x{(21 /02 \ I TMT ul t♦t � � qlf t I DEPARTMENT USE O LY / Application Accepted Byqy; Date___ O 2— Area ? �/� Employee ID# S3�C Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By Date—Rhz11 WAIVER Received , Destruction Inspection By Date U7� Constructed Well Depth ft COMMENTS PE SC Amount Check#/ Received Date Permit/ Invoiced WeII1D# Codes Info Remitted as By Service Request# 7 I - o ^�0 093 EHD 43.02.006 MASTER WA1"ER WELL PERMIT 5m=2