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WLLLL / rU1Vlr rLl KIVII I SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTHY- iRTMENT 304E WERE E3"FL-STOCKTON CA 95202 - (209)468.3420 NO EFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS LI XPIRES 1 YEAR FROM DATE ISSUED G n JOB ADDRESS 4343'McKinley Ave. CITY/ZIP Stockton 9526(0 > oZ3 '7k- CROSSSTREET 'TTt�a'• F-0. APN //yr — � PARCEL SIZE N OWNERNAME Sierra Organics PHONE OWNERADDRESS P. O. Box 31750 CITY/STATFJZIP Stockton,Ca 95213 ..� CONTRACTOR Purviance Drijlet--sj Inc. PHONE 209-887-3554 CONTRACTOR ADDRESS P. O. ox 64CITY/STATEIZIP Linden, CA 95236 SUBCONTRACTOR / PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSEC-57 ❑C-61 ❑D-09 ❑Other NUMBER EXPIRATION DATE 7/03 GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE ❑DOmesliC/Privale ❑Irrigation/Agricultursl ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization ❑Public Water System IfdifcmnrfmmO ner: Water System Name Coame, emeor Ph..Nutnber TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other (� ❑Monitoring Well(s) numberofwells 0Soil Boring(s) number of borings 13Geoteehnieal mealo,oflImmgs I LRWeII Destruction ❑Oui-Of-Service Well ❑Oui-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 ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diatpeter ❑Conductor Casing in diameter / Conductor Casing Depth fl Well Casing Diameter _ in ThickncWGauge/ASTM Sched ❑Steel ❑Plastic O Stainless Steel ❑Other Grout Seat Depth R ❑Neat Cement(94 111,hog/5.10 gal water) ❑Sand Cement .tock nox/7 gal water 0 Bentonite(20%solids) ❑Manufacturer Spec%solids_% Name ❑Specs on Fite ❑Specs Submitted Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other ❑Concrete Pedestal Dimensions: Width_ It Length_H Thick in ❑Christy Box ❑Stove Pipe PUMP ❑Submersible ❑Turbine ❑Other TIP Pump Set R Standing Water Level R WELL DESTRUCTION I4 Open Bottom ❑Gravel Pack ❑Uncased ❑Other Well Diameter 1 21in Total Depth 18 8 R Depth to Water .37' 0 13 Casing to be Perforated from R to R Seating Material ❑Nut Cement(941h hag/5-logo/water) ❑Sand Cement sack mix/7 gal water ❑Bentonite Pellets ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Placement Method W Ppmped ❑Free Fall QlOther use primaeord to blow casing ❑Complete with Mushroom Cap it below grade ❑Complete to Existing Surface Pad 1 HEREBY CERTIFY THAT 1 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 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. IMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS SHINE TITLE Corporate Secretary DATE 8/21 /02 PA I IN L + 1 . Out 41 AI H70 1F X, it 01 lz DEPARTMENT USE,ONLY / Application Accepted By Date 8 2ZArea Z L( _ Employee ID## �!/J Grout Inspection By Date ❑ SPECIAL Well Permit / ) ` Pump Inspection By Date 11 WAIVER Received �/ Destruction Inspection By � b Date Constructed Well Depth IT COMMENTS PE SC Amount Check#/ Received Date Permit/ Invoice# Well ID# Cast Into Remitted ash BY Service Request# 7 250 EH 43-02-006 MASTER WATER WELL PERMIT' 5nP002