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r <br /> %5V / 10/ <br /> m r3o) / a WELL/PUMP PERMIT <br /> SAN 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 1400 E.Victor Rd. CITY/ZIP Lodi,95240 n <br /> 0 <br /> CROSS STREET N.Guild Ave. APN 04932015 PARCEL SIZE 27.13 acres LAND USE APPLICATION# m <br /> N <br /> OWNER NAME PHONE N <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> CONTRACTOR Kleinfelder, Inc. PHONE 209-948-1345 <br /> CONTRACTOR ADDRESS 2001 Arch Airport Road,Suite 100 CITY/STATE/ZIP Stockton,CA 95206 <br /> SUBCONTRACTOR V&W Drilling PHONE 209-369-9600 <br /> SUBCONTRACTOR ADDRESS 3806 Duck Creek Drive CITY/STATE/ZIP Stockton,CA 95215 <br /> LICENSE v C-57 C-61 - D-09 Other NUMBER 720904 EXPIRATION DATE 4/30/2018 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y 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: Water System Name Contact Name or one Number <br /> TYPE OF WORK - New Well - Replacement Well -Well Alteration/Modification Other <br /> MonitoringWell(s) #of wells - SoilBoring(s) #ofborings ✓Geotechnical 7 #ofborings <br /> Out-Of-Service Well - Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement - Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method _ Mud Rotary Air Rotary /Auger - Cable Tool - Push Point - Other <br /> Proposed Well Depth 10-50 ft Excavation 6 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 Schad Steel Plastic - Stainless Steel _ Other <br /> Grout Seal Depth ft J Neat Cement(94 lb bag/8-10 gal water) Sand Cement sack mixf7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method a Pum ed V Free Fall - r • 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 /> PUMP _ 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 /> ° <br /> IN U HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE Project Geologist DATE 5-15-2017 <br /> I <br /> Y4% <br /> �/VF® <br /> ` 6 201, <br /> J <br /> y T l fHpqUN�Y <br /> RTj yFNT <br /> 7 If <br /> few <br /> PAR MENTT U�Y <br /> Application Accepted By MA[ AreaEmployee ID#_ � <br /> Grout Inspection By Date *LPECqlALW.11 Permit <br /> Pump Inspection By Date L WAIVER Received <br /> Soil Boring spection By J Date tructed Well Depth ft <br /> COfjQjvIENTS l L Cc <br /> PE Sc Received Check#/ Amount Date Permit] Invoice# Well ID# <br /> Codes Info By <br /> Cash Remitted Service Request# <br /> DD 1 003 0 <br /> EHD 43-06 vr�S�� (may WELL/PUMP PERMIT <br /> 4/30/12 <br />