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Or <br />PAE <br />REcE <br />AUG 11 <br />SAEN�RpNM R��T�'�DEPARTMENT USE ONLY '7I (� /} <br />pEpp Ion Accepted By _ Date % Area / Employee ID# �! M <br />N�A�iH Grout Inspection By ate rl SPECIAL Well Permit <br />Pump Inspection By 7 1 _ 7 Date I / J /" d�L Pi WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />NUIv-KEFUNDABLE PERMIT WWW.sIQOy.Org1ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 11222 E Fairchild Rd Cm21P_Stockton, CA 95215 <br />CROSS STREET Beecher Rd APN 08911021 //�� PARCEL SIZEI -0 LAN DUSEAPPLICATION# <br />OWNER NAME Joe Ghio/ Ghio Farms, Inc -- / ILN r-7 G"(Its PHONE <br />OWNER ADDRESS 11222 E Fairchild Rd CITYISTATE/ZIP_Stockton,CA 95215 <br />CONTRACTOR Purviance Drillers, INC PHONE 2 0 9 - 8 8 7 - 3 5 5 4 <br />CONTRACTOR ADDRESS P. O- BOX 64 CITY/STATE/ZIPL inden CA 95236 <br />SUBCONTRACTORICONSULTANT <br />PHONE <br />SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATEIZIP <br />LICENSE k C-57 C-61 -I D.09 Other NUMBER 377923 EXPIRATION DATE 7 3 1/ 23 <br />BILLING PARTY: ;OWNERCONTRACTOR .l SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: G General Mineral/Coliform Bacteria (4391) 2 Dibromochloropropans (4392) L Arsenic (4393) <br />INTENDED USE Domestic/Pnvate 7]Irrigation/Agricultural :: Industrial : Water Quality Monitoring is Soil Sampling/Characterization <br />Public Water System <br />If different from Omer:. Water System Name Contact Name or Phone Number <br />rre yr wuhK -_ Ivew vven I: Replacement well Well Alteration/Modification 7 Other <br />Monitoring Wells) #of wells j Soil Boring(s) #orbormgs [I Geotechnical #of boings <br />= Out -Of -Service Well ❑ Out -Of -Service Well Renewal i! Cross -Connection Repair <br />C New Pump )!?ump Replacement ❑ Pump Repair a Raise Well Casino <br />Drilling Method -. Mud Rotary Air Rotary C Auger Cable Tool [ Push Point L Other <br />Proposed Well Depth ft Excavation in diameter .,, Open Bottom i'. Gravel Pack/Gravel Size in diameter <br />:7 Conductor Casing in diameter ! Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Schad Steel C Plastic t; Stainless Steel [I Other <br />Grout Seal Depth ft Neat Cement (94 /b bag/5-10 gal water) E Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) Ll Other <br />Grout Placement Method f ; Pumped : i Free Fall I i Other ! i Retardant I Accelerator (name) <br />PEDESTAL Installed By L; Driller Pump Contractor t- Other <br />Concrete Pedestal CDimensions: Width It Length ft Thick in ❑ Christy Box Stove Pipe <br />PUMP XSubmersible i! Turbine " Other HP Pump Set i fl Standing Water Leval fir^ C� s. <br />1 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. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />m <br />m <br />D <br />0 <br />A <br />y <br />PE <br />Codes <br />SC1 Received <br />Info <br />Check#! Amount Permit/ <br />ash Remitted at Service a ue # Invoice # Well ID# <br />3b-; <br />h <br />- _ - B0 <br />_ /'? , / ,y L rJ WELL /PUMP PERMIT <br />