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AIR <br />' WELL/PUMP PERMIT / <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209) 468-3420 <br />L <br />NUN-KEFUNDABLE PERMIT (:ALL (ZU9) 953-7697 FOR INSPECTIONS <br />tXPIKE:S 7 YEAR FROM DATE ISSUED <br />1102 W. Kettleman Ln. <br />Lodi, CA 95240 <br />JOB ADDRESS <br />CtTYMP <br />CROSS STREET <br />S. Fairmont Ave. ApN 06004018 <br />PARCEL SIZEI.1 acre LAND USE APPLICATION III - <br />OWNER <br />OWNER NAME _ <br />Miner Joaquin Building Corp. (John Dentoni) <br />PHONE 209-929-1433 <br />OWNER ADDRESS <br />P.O. BOX 1110 <br />CITYISTATEIZP <br />Stockton, CA 95201 <br />CONTRACTOR <br />ants,n <br />PHONE <br />CONTRACTOR ADDRESS <br />14 1 , ul a <br />CITYISTATE/ZIP <br />SUBCONTRACTOR <br />V & W Drilling, Inc. <br />PHONE 209-469-7700 <br />1133 Blackhurst Drive <br />Galt, CA 95632 <br />SUBCONTRACTOR ADDRESS <br />CITYISTATEMP <br />LICENSE IN C-57 <br />❑ C-61 ❑ D-09 ❑ Other <br />NUMBER 720904 <br />EXPIRATION DATE 4/30/2020 <br />DOMESTIC WELL SAMPUNG: ❑ General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) ❑ Arsenic (4393) <br />NTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring X Soil Sampling/Characterization <br />D Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK ❑ New Well ❑ Replacement Well 7 Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells X Soil Boring(s) 4 4 of borings D Geotechnical A of borings <br />D Out -Of -Service Well D Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />L <br />sa <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary X Auger ❑ Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth 25 ft Excavation 8 in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth It <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Scher) ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth 25 It X Neat Cement (94 Ib bag/5-10 gal water) ❑ Sand Cement sack mixf7 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped X Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor D Other <br />❑ Concrete Pedestal ❑Dimensions: Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br />PUMP D Submersible Turbine ❑ Other HP Pump Set ft Standing Water Level ft <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 />MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED TITLE Sr. Staff Engineer DATE 6/27/2018 <br />N <br />D <br />mm <br />w <br />D RT ENT U E /OW <br />r <br />Application Accepted By / Date Area Employee]D# <br />Grout Inspection By Kate % PECIAL WeII Permit <br />Pump Inspection By Date WAIVER Received <br />Soil Boring %sspectionj By Date Constructed Well Depth ft <br />COMMENTS . `�f)/ /,/ <br />EHD 43-06 revised 4/14/18 <br />WELL /PUMP PERMIT <br />