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SAN JWELL/PUMP PERMIT <br />OAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />.NON-RIEFUNDABLE PERMIT <br />www.sigov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS Fairchild Rd <br />A�rC/I <br />�ITY/ZIP <br />R <br />CROSS STREET Beecher Rd APN08911023 ., k'j c(C Stockton, CA 95215 <br />OWNER NAME Ghio Farms s C 0 <br />OWNER ADDRESS 11222 E Fairchild Rd <br />CONTRACTOR PUrviance Drillers, INC <br />CONTRACTOR ADDRESS P - 0. BOX 64 <br />SUBCONTRACTOR/CONSULTANT <br />2CEL SIZE r ( LAND USE APPLICATION # <br />I,',CAi1ONE 209-401 -1 305 <br />PH <br />CITY/STATE/ZIP Stockton, CA 95215 <br />PHON E 2 0 9 - 8 8 7 - 3 5 5 4 <br />CITY/STATE/ZIPL i nd e n CA 95236 <br />PHONE <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />CITY/STATE/ZIP <br />LICENSE X C-57 C-61 D-09 Other377923 7/31/23 <br />NUMBEREXPIRATION DATE <br />BILLING PARTY: 1 OWNER CONTRACTOR — <br />SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: G General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392), Arsenic (4393) <br />INTENDED USE }( Domestic/Private Irrigation/Agricultural Industrial C Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />If different from Owner Water System Name <br />��_�.ar ui rnone <br />TYPE OF WORK New Well <br />Replacement Well Well Alteration/Modification p Other rvumber <br />Monitoring Well(s) # of wells Soil Boring(s)# of borings <br />Out -Of -Service Well =Geotechnical #ofborings <br />Out -Of -Service Well Renewal Cross -Connection Repair <br />New Pum Pum Re lacement _Pum Repair 7DrillingMethod <br />TION Raise Well Casing <br />')( Mud Rotary Air RotaryAuger Cable Tool Push Point Other <br />Depth_ .3.2� ft Excavation / z n diameter Oen Bottom <br />Conductor Casingp Gravel Pack/Gravel Size in diameter <br />in diameter / Conductor Casing Depth ft <br />Well Casing Diameter6• LZn Thickness/Gauge/ASTM Sched. / $8 Y <br />x Steel Plastic Stainless Steel <br />Grout Seal Depth a•,!o/— ft 11 Other <br />Neat Cement (94 Ib bag/5-10 gal water <br />Sand Cement sack mix/7 gal water <br />_ Bentonite (20% solids) �i Other <br />Grout Placement Method K Pumped Free Fall L_ Other <br />Retardant /Accelerator (name) <br />PEDESTAL Installed By >4Driller __ Pump Contractor , Other <br />X Concrete Pedestal Dimensions: Width cJ ft Length ft Thick <br />in _Christy Box Stove Pipe <br />PUMP Submersible Turbine .:Other <br />HP Pump Set ft Standing Water Level <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 I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring inspection By <br />COMMENTS Cry <br />crai. vye i�'� i iu. t_ 'at, WkEL <br />/IDPARTMENT <br />Date <br />Date <br />Date <br />SPEC- IONS P1_ A,<"� r•R,e r i-�nr?, n.F <br />Corporate Secretary r,�T� 9/1/21 <br />I Employee ID# <br />SPECIAL Well Permit <br />WAIVER Received (' <br />ucted Well Depth yid <br />EHD43-06 6/11/2019 <br />WELL /PUMP PERMIT <br />T <br />-a <br />M <br />D <br />v <br />0 <br />M <br />m <br />Cn <br />(/1 <br />