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WELL/PUMP PERMIT <br />vAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 223 A Cherokee Lane CITY/ZIP Lodi / 95240 <br />- <br />CROSS STREET Railroad Avenue APN 043-202-10 1 acre <br />% n /�- _ I PARCEL SIZE LAND USEAPPLICATION # <br />OWNER NAME lO ka � PHON42—c�& <br />J 7 �L_L <br />OWNER ADDRESS 1 7 ' �, +p <br />/j <br />CITY/STATE/ZIP <br />CONTRACTOR Kleinfelder, Inc. <br />PHONE 209-948-1345 <br />CONTRACTOR ADDRESS 2001 Arch Airport Road, Suite 100 <br />CITY/STATE/ZIP Stockton, CA 95206 <br />SUBCONTRACTOR Pitcher Drilling Co. <br />PHONE 650-328-8910 <br />SUBCONTRACTOR ADDRESS 218 Demeter Street CITY/STATE/ZIP East Palo Alto, CA 94303 <br />LICENSE ED C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER 263085 9/30/2019 <br />EXPIRATION DATE <br />GEOGRAPHICAL INFORMATION: COOrdinates X Y <br />Township Range Section <br />INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br />Public Water System <br />If different from Owner. er ys em ama <br />Uontact Name orone um <br />TYPE OF WORK ❑ New Well 0 Replacement Well ❑ Well Alteration/ModifiCation 11Other <br />[IMonitoring Well(s) # of wells []Soil Boring(s) # of borings ❑ 2 <br />eotecGhnical D <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair Air'. <br />❑ New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casin ®? <br />WELL CONSTRUCTION <br />JOq <br />Drilling Method 0Mud Rotary ElAir Rotary OAuger ❑ Cable Tool ❑ Push Point ❑ Other yE9 Vl"I O�lJy71, <br />Proposed Well Depth 30-50 ft Excavation 4-8 in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Sizep�rR? diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft ryT <br />Well Casing Diameter. in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth ft E] Neat Cement (94 /b bag/5-10 gal water) ❑ Sand Cement <br />sack mix/7 gal water <br />❑ Bentonite (20% solids) 11 Other <br />Grout Placement Method I] Pumped E] Free Fall ❑Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal ❑Dimensions: Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br />DIUMP ❑ Submersible❑ Turbine ❑ Other HP Pum Set <br />P ft Standing Water Level ft <br />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 />:URRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />YORKERS COMPENSATION LAWS. <br />MINIMILM24 HOUR ADVANCE NOjICq REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />iIGNED C 6 f 171 �illw TITLE Manager 10/27/17 <br />—T—i---,—,—, DATE <br />to <br />r <br />Ji <br />+� it <br />T <br />M-1 <br />D <br />v <br />0 <br />M <br />N <br />Cl) <br />DEPARTMENT USE ONLY <br />Application Accepted By Date 2 Area >' Employee ID# w �m <br />Grout Inspection By Date ❑ 1 PECIAL Well Permit <br />Pump Inspection By Date 'f El WAIVER Received <br />1/ �e <br />Soil Boring Inspection By Date /` ✓ �1 ` Constructed ell epth U�UL��J 1 ft <br />COMMENTS I �� �I-i' r „� r Y G u <br />PE <br />SC <br />Info <br />Received <br />By <br />Check#/ <br />Cash�1 <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Well ID# <br />t�Codes <br />/l <br />Q <br />EHD 43-06 Ljo'c4 fro j(" '�K-) WFI I /PI IMP PFPMII <br />