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I WELL/PUMP PERMIT <br />SAN JCAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 46$•3420 <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 11_1 16_ Fa i rr-h i 1 dRd, CITY/ZIP Sf-nrk� (1A q S21 F <br />CROSSSTREET _Beecher RC1 APN O,991 1 023 PARCEL Sizq_2_ 7 LAND USE APP, ^"lN# _ <br />OWNERNAME Ghlo Farms, Inc, PHONE_, _ <br />OWNERADDRESS 11 222 E Fairchild RD CITY/STATE/ZIP Stockton, CA 95215 <br />CONTRACTOR Purviance Drillers PHONEPO9 RR7-3_554 <br />CONTRACTOR ADDRESS P.0 BOX 64 CITY/STATEiZIP Linden, CA 9 5 2 3 6 <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE $ C-57 ❑ C-61 ❑ D-09 ❑ Other <br />CITY/STATEIZIP <br />NUMBER3 7 7 9 2 3 EXPIRATION DATE 7/ 3 1/ 2 3 <br />DOMESTIC WELL SAMPLING:!-, General Mineral/Coliform Bacteria (4391) = Dibromochloropropane (4392) : Arsenic (4393) <br />INTENDED USE X Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Charagenzation <br />❑ Public Water System n YA4 <br />If different from Owner Water System Name Contact Name or Phone Nu Pr, �, , <br />TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings ❑ Geotechnical --J4f / rings <br />0Out-Of-Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair ��?2 <br />9New Puma ❑ Pumo Reolacement 11Pumo Renair n Raise Well Casino SA N. JOA n <br />VVELL ION <br />-uUN <br />EN <br />Drilling Method T❑ Mud Rotary ❑ Air Rotary ❑ Auger F1 Cable Tool ❑ Push Point ❑ Other HEALTH DE ARTMF Ty <br />T <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth ft ❑ Neat Cement (94 lb bagIS-10 gal water) ❑ Sand Cement sack mixl7 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant /Accelerator (name)-, - <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal ❑Dimensions: Width ft Length ft Thick <br />lin 0 Christy Box ❑ Stove Pipe <br />PUMP Submersible❑ Turbine ❑ Other HP '`, Pump Set \n`i5 ft Standing Water Level \y— ft <br />Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the following items: GPS <br />Coordinates, property lines, adjoining properties, water bodies or courses, drainage pattern, roads, existing wells, structures, <br />potential sources of contamination, sewers or private disposal systems. Include distance from two property lines. For Domestic, <br />Agriculture, Industrial well, provide location of any water wells or surface water within 200' radius of proposed well. <br />DEPARTMENT USE ONLY <br />Application Accepted By Date <br />Grout Inspection By Date <br />Pump Inspection By Date �'= ►� <br />Soil Boring Inspection By Date <br />COMMENTS Lti)P.) I tc' c .r i t ,fel F rJ 1) `4 J y 6! <br />+.t'r L;i-fs�c.ct !'C� �t��� �IIJ( •,nc i���iifPSS <br />Area �i Employee ID# ( <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth_ <br />.S Pr f'c;tt f 1 Vie"Jt'Y <br />ft <br />T <br />M <br />D <br />O <br />A <br />m <br />PE SC Received Check#/ Amount Date Permit/ Invoice # Well ID# <br />Codes Info BV Cash Remitted Service Re ues # <br />1;a 1 <br />' <br />EHDO43-06102512021 Page Ioft 1Vdl!Pump Permit <br />/372 75 Z3 <br />