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WELL/PUMP PERMIT <br /> SAN.IOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZE LTON 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 8477 E . Peltier�r`Rd ( CITY/2.IP Acampo / CA _ __. m <br /> CROSS STREET Bruella Rd. APN (/y7 OJ7 01 OARCELSIZE LAND USE APPLICATION# <br /> A <br /> OWNER NAME Vino Farms PHONE 209-334-6975 <br /> OWNER ADDRESS 1377 E Lodi Ave . CITY/STATE/ZIP Lodi CA 95240 <br /> CONTRACTOR Lodi Pump And Irrigation PHONE /209-368-5082 <br /> CONTRACTOR ADDRESS 1301 E Armstrong Rd. CITY/STATE/ZIPLodl A 95242 <br /> SUBCONTRACTOR Lodi Pump And Irrigation PHONE 209-368-5082 <br /> SUBCONTRACTOR ADDRESS 1301 E. Armstrong Rd. CITY/STATE/ZIPLodl CA 95242 <br /> LICENSE C-57 C-61 D-09 Other D21/C1 0 NUMBER EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> F <br /> NDED USE X 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 Phone Number <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells Soil Borings) #of borings Geotechnical #of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement X Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary I I Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depth ft Excavation 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 Sched Steel Plastic IStainless Steel Other <br /> Grout Seal Depth ft Neat Cement(94 Ib bag/5-10 gal water) Sand Cement sack mix/7 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 fl Length It Thick in Christy Box Stove Pipe <br /> PUMP XSubmersible Turbine Other HP 2 Pump Setj 7 1 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 DATE <br /> IV <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date ���V AreaqSPCIALL <br /> (Jt mployee ID# <br /> Grout Inspection By Date Well Permit <br /> Pump Inspection By {t�\V� Gw�� t` Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ® ft <br /> 1=` <br /> COMMENTS @rtY�l EN <br /> PE Sc Received heck# Amount Date Permit/ Invoice# Well iCode Info B as Remitted Service Re uest# <br /> 018 <br /> UIN C UNTY <br /> PNVIRONME TAIL <br /> HEALTH DEPARDEPARR MENT <br /> EHD 43-06 revised 4/14/18 WELL/PUMP PERMIT <br />